HomeMy WebLinkAboutR2020-0966 - Permit ApplicationO-GSIVED a).
Print Form City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DFvC:.i OlDMEN?
BUILDING DIVISION NOV 17 Z0Z0
%/°{' Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# �" f www.newportbeachca.gov (949) 644-3200 uITY OF
App ication for Report of Residential Building Recordky,,,,,,,,. �F�i
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: 11 11 1._,_ �,, f Cit New ort Beach -' State: CAZi
Property Owner: `Ponc0 6 )- �-pg' a��(' Zip Code:
-Owner Address: Q;753 Camay City: CQY�'Y1r� m�
State: CA Zip Code:FCf.:aS Home Phone:
Owner's Authorized, `` �,LY,� /���`'��..ij' Work Phone:
Agent Address: lS`1� �1 V�P6�r� \ . �{� city:. _. 4(�—(C>L �A
State:
77 Zip Code: _ q 5E� LET Agent Email Address:
V
Escrow Company: Escrow #:
Escrow Address: �_P UD 1 1(13 f�'� ._��`�r City:.. 7 (i' „--a Gw
State: F Ii Zip Code: "L'17Q, o I Escrow Phone: qlq _ l qL4
Email Report to: I3\0 .�rUjc, \1SC L0-C-i,-,�
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 l will be responsible to correctsaid violations.
Owner/Agent's signature to authorize inspection: /n/ Date:I
Owner/Agent's signature to decline inspection: �,. / 1 Date:
Account # 01050504-521040 .................Make checks nnvnhle tnr [ITV OF NFWPnRT RFArm
8v11ding Division\Forms\RBR_7-30-20