HomeMy WebLinkAboutR2021-0254 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELGPMEKT DEPARTMENT
BUILDING DIVISION
02 r�100 civic Center Drive I P_U. Bast 17681 Newport Beach, CA 92658-8915
RBR# LU ✓ www_ achca_gov 1 (949) 644-3200
iippimation Tor Kepor[ OT Kesidennal Building, Records
Application Fee: - $194.60 Nice.
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.0 or incomplete will be returned
Please type or print and complete all information
#of Units: 1 ! Address: a �oC) (1 View: Newport Beach state: Zip: 7�6(p
PropertyOwner. 014Narn����GSI' tQ�GIIIG *5G1 Ihi1V11bt75 ((Rjt@�e Zip Code: F
Owner Address: FT7 (c) 3 /tet/ �/le� I �� co cityNe wpo ct Bead I/ 1
State: �— Zip Code:Gj ;69 O dome Phone: Gj [ f q G V
Owner's Authorized Agent: `(? , / /_ Work Phone: I -1 i I 3 J L T 1
Agent Address: K�lfe 30 /1 city: l fU t� fl l/I<Sfdn Bc),-tah
State:— Trp Code: q,; I6 Agent Email Address: bCo-& y ha6�11 (090CLO, lie�4
l e fiiGl � F e a) (.t) Escrow d C FCS 90 IO�J
Escrow Company- I )f / ,r� ey C1 I
Escrow Address: 19)W ftkt v) J I S c 105 �" Flo 4 m 9 -6Dn 6(oa(y,
State: Fj � J� Trp Code; q (4 Escrow Phone: �G1 6q�( Q �j
Email Report to: 1 (�me!� @Q een( rCl e5erm grocy, , co{ i� u- t
For Inspection call (Name): I Direct Phone: �—
CONSENT TO INSPECT fFORM MUST BE SIGNED & DATED BELOW
I authorize inspections and re -inspections of the property listed above. l 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:
�/� //9OR
Owner/Agent's signature to decline inspection:/ Dater_
Account 4; uimo5o4-521o4o .................Make checks payable to art, OFNEWPORT BEACH
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