HomeMy WebLinkAboutR2021-0566 - Permit ApplicationDocuSign Envelope ID: A69F76CC-FDEO-42CA-AD73-1 C5218F21E12
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City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 I Newport Beach, CA 92658-8915
RBR# www.newportbeachce.gov 1 (949) 644-3200
Application for Report of Residential 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
tt of Units: PSyto Address: C2CSivi ew-bem's' City: Newport Beach State: CA Zip; C�j2tat�3
PropertyOwner.I lc -,W4 pr J -Oh N S-�,DN
Zip Code:
Owner Address: } pjaJ 4t (1, ) VVI Orj W City: PIS L- C,IT
State: .: Zip Code: Ot.p0 Home Phone: Ctte,,1 t�4 -iULI i
Owner's Authorized Agent: I ao-'K
Agent Address: 7 r5i 5,c, kcc&kc 4- tOD City:
State: I CIA Zip Code: 'I 2-IWq t Agent Email Address:
Escrow Company: I ec-ek -1Gi ti5(-g6A
Work Phone: I w-,, tot- ' 11157(—
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Escrow #:I
Escrow Address: I Z,,�G `mooAwu) _ .5 . I Ib City: I H1'SS1Ut l V1 r-- J%
State: i Zip Code: �//�tt`Z, .P a I Escrow Phone: CI (4ct —I 6-1 - t, 6tO }
Email Report to: "V�-lUT Es(1y.UvJ.iil)t�
For Inspection call (Name): ' 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 or Zoning
violations are discovered swill be responsibleto correct said violations.
Owner/Agent's signature to authorize inspection:
Date:
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Owner/Agent's signature to decline inspection: v Date: $/5/2021
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Account 9 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH