HomeMy WebLinkAboutR2021-0344 - Permit ApplicationCity of Newport Beach
MMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT �UrlMMUNI-ry
BUILDING DIVISION
n Q__ 100 Civic Center Drive I P•0• Box 17681 Newport Beach, CA 92658-891 ;, �y q F W1RBR# Y/� www.newportbeachca.gov 1 (949) 644-3200
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Application for Report of ReslOentiai isunaing Kecoras
Application Feet: -•ti 1 0 I No_ tics;
For.'AIi.4teFi'deritE�l.Bui{d[ngg)' bppli'cati'ons:with.ihsu�cient•£e#•payment:
Rernspedion•Fee:$�129:00:� .. orih'rnmRletewill:Be;iie'turned:
Please type or print and complete all Information
# of Units:1 Address:�GV t Clty; Newport Beach State: CA ZIP:
Property Owner: N Zip Code;.
Owner Address: City: 1V 0v" as
State: CA Zip Code: �2✓iQ�1 Home Phone: 22 c) O�
Owner's Authorized Agent: Y Work Phone:
Agent Address:�j Z IV T kv y, Citi: 1 (C�( �
State: Zip Code: L / Agent Email Address: h'in ry\-a" br(Pad n
Escrow Company; Escrow #; r
Escrow Address: /1,�01�G City,
State: Zip Code: Escrow Phone:
Email Report to:
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
PaxthzMze Inspectron's.andre-{inspection's of -the property listed above. I understandthat.if 6G11ding•or2oning.
vialationsare.discovered:l WdlI:bd:rrsponsibl'e.to correctsai''d vrnlatrons•
Owner/Agent"s signature•to• authatrfze •rnspectl'am:
,1'I '•u�Signadddb��y:������LL�
owner/Agemt's:Mgnatureto decitme.inspectrom: �ILUAIM ra 0yt 1 Date. ® �
Account # 010SOSO4-521040 .................Make checks payable to: CITY OF NEWPORT peach
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