HomeMy WebLinkAboutR2021-0582 - Permit Application„,ACL'=iVEly 6
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Print Form City of Newport Beach or_vl_LO F>
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COMMUNITY DEVELOPMENT DEPARTMENT AUG 12 2021
BUILDING DIVISION
100 Civic Center drive 1 P.O. Box 97681 Newport Beach, CA92658-89 j�,,,,r_
RBR# www.newportbeachca.gov 1 (949) 644-3200 11
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Application for Report of Residential Building Records PDR .T P FP�<�”
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pection Fee $129.00 Applications with insufficient fee payment
or incomplete will be returned
Please type or print and cornol®te all int®rtteation
#of Units-, Address: ����— ��^^, �y TI,),
' -. E0 fl.. � 1 City: 1Vewport Beach . State: ZipFro(-.43 C /3
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7 "r7�'C�.'^f�..� � �® �i3 ✓�.�'i Si�-g Zip Code•.
Owner Address II,Z� t1i�x7 City:
State: i"" Zip Code:7!
L �f� Nome Phone: 9Lf�,.1-��--y`�,
Owner's Authorized Agent: /� Work Phone: �p
Agent Address:�-h
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State: lfl Zip Code;✓ Age mail Address:
Escrow Company:i ,.1' °'. ,, „>l C� i
Escrow Address: `"
State: ZIP Code: i - ,
Email Report to:
Escrow#:(
Escrow Phone:.
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For Inspection call (Name):
Direct Phone: F�
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'authorize inspections and re -inspections of the property listed above. I understand that if Building orZoning
violations are discovered 1 will be responsibietocorrect said violations.
owner/Agent's signature to authorize inspection: y� —
6 Date: IJ 110021
OR
Owner/Agent's signature to decline inspection:
bate:('1�:,;-by, -
ACCOunt#01050504-521040.................Make checks payable to: CrtY®F NEWPORT BEACH J
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