HomeMy WebLinkAboutR2021-0575 - Permit ApplicationDocuSign Envelope ID: 3E935199-EB9F-40EF-9605-FE516C6287B8
Print Fon„ . City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
V d� _ 11-_ In100 Civic Center Drive P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# IIff4/ 4 q 10 www.newportbeachca.gov 1 (949) 644-3200
Appimaxion Tor Keport OT Kesldentlal Building Records
Application Fee: - $198.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $131.00 or incomplete will be returned
Please type or print and complete all information
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Property
Owner Ad
State: I_.. _ Zip Code:
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Home Phone:
Owner's Authorized Authorized Agent: jZ�On /n 1.. 1p)®I'�C�Work Phone: Lq04 —14k44 3:2-3
Agent Address rr`..—.V(){/Cly �V� City: i� ✓�G��1Ar1(i�
State: Zip Code: „l !tel!' `I 8' Agent Email Address:
Escrow Company: VY%V��( Escrow #:
EscrowlA�dd7ress�—j(}Z y1Z g�,v !.ZO City: r j � Sf–I N +�
State: ! .F1' Zip Code: (� Escrow Phone:
Email Report to: SI/1 9 b W M 4VAWC0eV V 6 ,6S M-4) 6�
For Inspection call (Name): j Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections ofthe 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: r— �-
OR
acuSigned b : DocuSignetl by:
Owner/Agent's signature to decline inspectio f� �Gayy UjbDat
e 8/9/2021
02 � 5BOC435102784AE... 1AAEBAC10133409_. — ---_
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building BivisanyomsvBR )-1-21