HomeMy WebLinkAboutR2021-0683 - Permit ApplicationPFInt Fbrm.:
City of Newport Beach
COMMUNITY DEVE40PMENT DEPARTMENT
BUILDING DIVISION
�ZU ('�b3100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newpodt)mchca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fee:-$198.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspectlon Fees 131.00 or incomplete will be returned
Please type or print and complet all ll IdaClrlation
# of Units: Address: Z 53`% Urj(/f�W PL -#-V Maty: Newport Beach State: � zip: f /t� q / r526
Property Owner. -r#9 STk44- m5jLo r,¢rni1 7K—v.57— , tL p—aZZip,C,ode:I
Owner Address: � z9 � l hmotid sr City: 4{l�N/T ,Oc? , c—�r �s ' /
State: F Zip Code: f duo C/ Home Phone: /�y 5j Z 0 S'T
Owner's Authorized Agent: 1 r;C5 ( Pols Lic) e 4t4w, LJI L
Agent Address: I Z11TYJ L f% /fi 2 KCI (%NIT C-. aty: I LA6 UrJA- Al /GEL
State: CA Zip Cade: 19 24] 7 Agent Email Address: ICES 10 CAS / Pros Rn/U, CO r✓�
Escrow Company:jl ESCeQQ / Zax)i e�eJEscrow #:
Escrow Address: 13�� iO Wv` Ob1S o ) Stnie, too City: Tuo-n Gxy%iskfa#\D
State: f CA Zip Code: C[�L61s- Escrow Phone: ISoi) ab3?3—lot
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Email Report to: I k�"� �' esc rowle iAtrs . cared
For Inspection call (Name): I Ces i 'Pt l-to-I 1fo Direct Phone: 1949 370 O O$ I O
I authorize inspections and re -Inspections of thelub—p—eft listed above. I understand that if Building or Zoning
violations are discovered I will be responsible correc d viola
Owner/Agent's signature to authorize inspectlon V / Date: I� q-2/
OR
Owner/Agent's signature to decline inspection:
Date: I
Account # 01050504-521M.................Make checks payable to: CITY OFNEWPORT 894CH
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