HomeMy WebLinkAboutR2021-0220 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
D n^ 1 100 Civic Center Drive P.O. Box 1768 Newport Beach, CA 92658-8915
RBR# �`,cU www.newportbeachca.gov 1 (949) 644-3200
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: F Address: 17 '17��q /�u „ /
City: Newport Beach State: CA. ;Zip:
Property Owner. JT -w .... r..,ha //...
Zip Code:
Owner Address: 9% (.8M/r((/U
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Home Phone.
Owner's Authorized Agent: ! SU.MM-e W
Work Phone: q) 6/31,2 -,a99Q _
Agent Address: I J1 � //u,�J—
City: 5f✓'al a W /Z/Lvz
State: I N7 Zip Code: F�)&;5 Agent Email Address: IU 7— 79a / 41 —t
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Escrow Company:....Q �/U'I_�/(.�..
Escrow #:rv13��/((��a�' 129Y;2- �.
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Escrow Address: ....SyV /V�POlt 61hL.0.../07. 4/i0
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Escrow Phone: 9lg7 - 75g- //6 �Z
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Email Report to: t) ti. hehiX 8 cv2s�coQs ..es�ac�. '�%I%l
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For Inspection call (Name): 0
Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections ofthe 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. ,GS�tGhDate:
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Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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