HomeMy WebLinkAboutR2020-0910 - Permit Application°Print Form
RBR# 0 0 — 0 110
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 Newport Beach,
www.newportbeachca.gov (949) 644-3200
2.5-/43�,(
CA 92658-8915
Application Tor tceport or tcesiaentlal tsunaing rcecoras
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: City: Npreach State: CA :.ZiPc
Property Owner: /e-7/
Zip Code: 9 Eos
Owner Address: / /l7 7y7��=UG City:
State: CA Zip Coder 5 Home Phone: 1
Owner's Authorized Agent: l�z���� P VI,7- k Work Phone: yY_43c,?
Agent Address: P/�� - City: 1 %l40Ac� �
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State: �® Zip C/ ; c� ode: /cl6—Agent Email Address: ` C�/��z/
Escrow Company: Escrow #: bd o". ioj d j,°- 5 &H
Escrow Address: City:
State: 1 Zip Code:.�� Escrow Phone:
Email Report to: 0�
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:
Me.
Owner/Agent's signatureo decline i spection:
Account # 01050504-521040 .................Make checks
Building Division\Fo,.f\RBR J-3030
Date:
Date: 1__._-.___._.
16/161,21,ZO
to: CITY OF NEWPORT BEACH