HomeMy WebLinkAboutR2021-0214 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
�4�1 n 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
RBR# L www.newportbeachca.gov 1 (949) 644-3200
ApPiieaiiOii fur ReparL of ReSiaL-hliai BUiitiirta ReLoras
Application Fee: -$194.00 Notice:
(For AlIResidential 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: 12 ��(gj�U City: Newport Beach', State: CA 'Zip: qr-�/,_�<-I
Property Owner: t„/Q��,Rr CM1M0))r1 f � y..� s� Zip Code:
Owner Address: �
�.."[�5 `6's�^/S/l_k/. ."�'..._.('', City: _.a '„",_4//._..
State: CA. _..... Zip Code: �f ;?Js
Home Phone: I ( �75 i %x.8-3
Owner's Authorized Agent:Wy % C,24--- Work Phone:
Agent Address: •_%i__ _. City:
State: w', Zip Code: �d Agent Email Address: �W�-(�r�lr wvl / ✓e�J- �, �
Escrow Company: ,/j/ I..._. _ .. _.. Escrow #:
Escrow Address ' l %p.. /{ l„"&T /t r✓\- ea 'L� City: � Q / f.. .
State: /`�� t % IZip C"oCd(Jel< �lii" Escrow Phone:
Email Report to:
For Inspection call (Name): Direct Phone:
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 violations.
Owner/Agent's signature to authorize inspection:
Date:
OR
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Owner/Agent's signature to decline inspection: Date:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building Division\Farms\RBR 7-30-20