HomeMy WebLinkAboutR2021-0576 - Permit Applicationi Print Form City of Newport Beach
tt COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING, DIVISION
RBB#b')1 100 Civic Center Drive I P.O. Box 1768 1(ew )ort Beach, CA 92658-8915
www.newp(
ortbeachca.gov 949 644-3240
Application for Report of Residential Building Records
Apttllcation Fee:-- $198-00 Notice:
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $131,00 or incomplete will be returned
Please type or print and complete all information
#of Units: Address: 7 / I City: New ort Beach State irCA—Zip:t2G2rJ'
Property 0wner:I ,oma ,r-1 . k ? tea (- �d I
Owner Address:C{�(A �rOA�UJ.� -a:2oS
State: CA Zip Code q-Z(P(/: 1
Zip Code: ' `(06 -! .
City: -� �<f e -
Home Phone: ff
Owner's Authorized Agent:G4 LeL i Ive Work Phone: l�qq e 9 10 \
Agent Address: '� L 1} O n C City:
State: FLA Zip Code. R"Zly ('z Agent Email Address: �
I c_ctnd�cx�ec� � avec �. corms
Escrow Company: r 0� V5 _ �511 6-6 Escrow #. i Jcy C D
Escrow Address: 4-205 City: FJ-43uo-, 1`yiW�(:,
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State: �_ Zip Code: ff Z(IT7 Escrow Phone: '_(Q2�`
Email Report to:
For Inspection call (Name):
C:-,6c-ro Q . Lo T!,\i
Direct Phone: F
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 or Zoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date: I
OR
Owner/Agent's signature to decline inspection: ,pd" AMNd Date:j/11/21
A 08
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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