HomeMy WebLinkAboutR2021-0191 - Permit ApplicationPrint Form 1,
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
k2OZo�/i��l ( 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
RBR#- V i
www.newportbeachca.gov 1 (949) 644-3200
for Report of Residential Building Records
Application Fee: - $194.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or Incomplete will be returned
Please tune or oda and comolete all informAWn,
# of Units: Address: '''l 'r�S-Q,{y� -, C� . City:. Newport Beach State: CA !Zip:%p��
Property Owner.���.._h.G1^tG' G�...._., i" \IIi X13-t���.tr. ..,......**�Zip Code:............. z Lr5_ J
Owner Address: �i"GMO-....--T
State: CA Zip Code: q"'ZUj, Home Phone: qq�, ., U�t.O.-3��-�,.,.!
Owner's Authorized Agent:QtYtr� l--oWC� Work Phone: �G�ICI-3q5-,-_ 03 O`j
Agent Address: 3Z'iJI Cj(j�Jkc\ LA!"1. 4c ZG2l tY: r t.tW.
State: Zip Code
Agent Email Address:
Escrow Company: G� ^ Oaks<<O� Escrow#:(�q-946-9 _ Cp
Escrow Address:
2`6ZOZ Ubcyo ��, X205 City: �L-AyrlA..N] SAL
State:�A Zip Code ZU, Escrow Phone: F ZS-G%S)
Email Report to: I
,525c.coeJ .corn
For Inspection call (Name): Direct Phone: �—
NsENj TO INSPECT fFORNtBE SIGNED & DATED BELOWI
I authorize inspections and re -inspections of the property listed above. I understand that if Building or Zoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
OR
Owner/Agent's signature to decline inspection: Shahriar Minokadeh
Bulldlne_OIVlslonVoms\RBP_7-30-20
Date:
Date: 03/15/21
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH