HomeMy WebLinkAboutR2021-0224 - Permit ApplicationDocuSign EnvelopelD: 1ED37C1A-49934FD1-AFFD-2547562392CB
mma Offl �a City of Newport Beach' �r
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COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
�2��-[ ®1.`�,p— 100 Civic Center Drive I P.O. Box 1768681Newport Beach, CA 92658-8915
www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
\alilidatron Fee: °$ "y 94.00 Nbtice:
For All Residential Buildings).,insufficient fee payment'
2elnspectionFee,$129,00''''.`oriricotnpiete,wiifberettrme'd' _
Please tvae Or print and comolete all information
of Units: Address: ( "ty:NewportBeach State: Zip:L`%�
-operty Owner:C L Zip Code:
wner Address: E City:
:ate: CA Zip Code: l� Home Phone:
Iwner's Authorized Agent: Work Phone:
gent Address: City:
hate: Zip ode: Agent Email Address:
scrow""Company: / d Escrow #:I
:scrow Address: ',/--,//���n� City:
;tate: Zip Code:�Cjr Escrow Phone:
:mail Report to:
:or Inspection call (Name); Direct Phone: I
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I a.uthonzeinspections.and re inspections ofthe propqrtyaisted•above I Understand that If Building drZoning
violations' ,re disco4ered l•will be eesporrsibleto correc'i' violations'; ` , : '
Owner/Agent's signature to authorize Inspection: Date:
Owner/Agent's signature to decline inspection: y """`"7 Date:
Account # 0105 05 04-5 21040
uilding DWision\Ponos\RRR-9-18-10
checks nava a to: CITY OF NEWPORT BEACH