HomeMy WebLinkAboutR2020-0960 - Permit ApplicationEmm City of Newport Beach �C9NED Q,
COMMUNITY DEVELOPMENT DEPARTMENT COMMUNITY
BUILDING DIVISION DEVELOPMEI i
rpm 100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA9265i@9163 2020
RBR# '—U M 01 b0 www.newportbeachca.gov (949) 644-3200
Application Tor hceport or fceslaential i3uuaing Kecoras
Please type or print and complete all information
#ofUnits:Address: 919 E. Balboa Blvd. City: Newport Beach State CA ,Zip: 92661
Property Owner. Groundswelllnvestments LLC Zip Code:
Owner Address: City:
State: CA J Zip Code:J Home Phone.
Owner's Authorized Agent: '.... Work Phone:
Agent Address: City:
State �) Zip Code: Agent Email Address:
Escrow Company: Freedom Escrow Escrow #:054177 -MM
Escrow Address: 1200 Newport Center Dr., Suite 180 J City: Newport Beach
-- -- —
State: LCA -� Zip Code: F92660 Escrow Phone:(949) 644-3939
Email Report to: mm@freedomescrow.com '..
For Inspection call (Name): N/A Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
1 authorize inspections and re -inspections ofthe,property listed above. I understand that if Building or Zoning
violations are discovered l will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date:
® OR
Owner/Agent's signature to decline inspection: �L Date: //• (�-�
Account # 01050504-521040 ................. Make checks payable to: CITY OF NEWPORT BEACH
Building Oivislon\Forms\RBR_)-30-20