HomeMy WebLinkAboutR2021-0202 - Permit Applicationh CEIVE(7 6-y
COMMUNITY
Print Form City of Newport Beach DEVELOPMEN,
COMMUNITY DEVELOPMENT DEPARTMENT MAR 18 2021
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# G LI/ L, www.newportbeachca.gov 1 (949) 644-3200 CITY Of
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Application 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 type or print and complete all information
#of Units: Address: 1� �/jhvtC� City: Newport Beach; State: CA %Zip: 9LY V ® j
Property Owner. TGtkevMA L. L..-('.-.,.. _..-.. __. .ZiipCCode: G-Y�
OwnerAddress: 12 V (t/�lL�✓ City 1 rG��(�d(`� C�i�.Ok)_
State: CA, Zip Code: -I Z (P (0 Home Phone:
Owner's Authorized Agent:Com%.... ,J y `+ 0--A „/� Work '�'
/Phone: q q C, j �j t_Si(j
Agent Address: 2�O3&I c�� �✓�-..- y(i/� city: .._
State:Zi g r�ler..J�(Va i t? IOCICt .
C� p Code: "I 9 / ', Agent Email Address:
Escrow Company: 01" Y�ey^Escrow#: g®O— 12.7f / —_-. 7
Escrow Address: 2,— ,0i ...
— CA of R ..xyl vV City: _ LCtjlvte,/ /V,) j
State: C Zip Code: �2(„n'�. I! Escrow Phone: q77, 3�2-3 J%003
Email Report to: 'L..//(.'.VGC7rYl.¢iy"r�/Sc-.c--tJ�•C�Z}'trl"' _... __. _. _..... _._
For Inspection call (Name): Ale -c- 4Va 11 Direct Phone: yC' _ � 5 y 34 S.
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
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 'olations.
Owner/Agent's signature to authorize inspection:Aa45;ro— Date:
OR
Owner/Agent's-signature to decline inspection:
Mlding_Dwi,,.,\Forms\RBR7-30-20
Date:i
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH