HomeMy WebLinkAboutR2021-0067 - Permit ApplicationCity of Newport Beach cal,,iflnuN;sr
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION .)AN 2 6 IRFIC'J
I� d�,� 100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA9265B-8915
RBR# d- www.newpcirtbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Recordsf% , J`r
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- Avoliiatibn Fee::-$, �.q I Notice: '
(Foe AlLViesrdential.Build�ngs) ppptiLationswith-ihsufficientfee•pagmenL:
Rernspection. F.ee$•Y29:DD: er imorimpl -te will: be: veturned'
Please type or print and complete all information
#of Units: I I {Address: City: Newport Beach State: [C -A jZp: T( -V&
Property Owner. I-e.e ; W1 Zip Code;. 'l
Owner Address: 7 ITa , z \P L city' tw ck-,-E IS
State: CA Zip Code: lt. Home Phone: lm ''55-o 05-3
Owner's Authorized Agent aim �i / Work Phone:
Agent Address: �� 7 y LCity: A(r l� t
State:' I Trp Code: Agent Email Address:
Escrow Company: Escrow 0:I CUM
z
Escrow Address: City:
State: Zip Code: Escrow Phone:
Email Report to:
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I author ze iraRections.andce=ir spections afthe property listed above. I understa id,that.Ff B'u.ildingwZoning.
vialatioresare.discovered1 W .iU be:resp6nsi6l'eto correctsa d violations.
Owner/Agentssignatumto authorize inspectiam: Date:
R
Owner/Agent'ssignaturetodeciine1nspecdom. Date,-
Account
ate:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT. BEACH
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