HomeMy WebLinkAboutR2020-0959 - Permit Application,gscmv,6
Print Form City of Newport Beach COMMUMTr
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION NOV RcC'D
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# UU .0,, 61 www.newportbeachca.gov 1 (949) 644-3200 c;� CE!J i_pPiy; ivT s
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Application for Report of Residential Building Records �'eu�aoRz
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
R of Units: FTk Address: 1 oc` City: Newport Beach State: C;L
Zip: (p (P
Property Owner:�if0C-03e ZipCodef
Owner Address: (�;5 rO✓ cR, �G` �Ss l�i�� City:
State:IF v Zip Code: sci IT b Home Phone: � f � � `i� �' 7 f_
Owner's Authorized Agent: I �j�C� \l��1 f "� Work Phoned (I L� •-( (�� qck
Agent Address: \lkC)6C-,), C)(\%CL City: SCIY�\
State: I C Zip Code: F97 -7M Agent Email Address:
Escrow Company:
Escrow Address: I (-I a jD i= F7 .—&� -�k a-C)CD City: 1
State: i:\ Zip Code: g ai g o
Email Report to:
For Inspection call (Name):
Escrow H: I u5 — r t r, -g."-' RV
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Escrow Phone: -I i Lf -� r I _ `a C)
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 orZoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date: �—
OR
Owner/Agent's signature to decline inspection; y r ��Jj ;�c� Dater --
Account b 01050504-521040 .................Make checks payable to: CITY of NEWPORT BEACH
BWIft-W Obny .ARBP 1-30.20