HomeMy WebLinkAboutR2021-0808 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
ROW 100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA 92658-8915
RBR# www.newportbeachca.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
# of Units: I �" .Address: O /)„(, &(W SE _ n VE City: Newport Beach State: CA ;,Zip: gzz,�Sz
Property Owner: J�-{✓1`,yi--v\..,, C-1 J,•) 1.•)_c1 -- Zip Code:
Owner Address: I HL0 C LQi3k(b'4S� 4W(F. City: - �1'6V6�_ 7«
State: CA l Zip Code: ��?�, Home Phone:
Owner's Authorized Agent:
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Agent Address: I �,L� New �]�,� L D���
State Zi Code T�151
Work Phone: I cli-lo Z/ip� S
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City: V k;o i" P—E:- #4"
C 4 P �2 �� Agent Email Address:
Escrow Company: I C uV\% Escrow #:
Escrow Address: Z 0 -1 b Z City: i y 11_(},'1
State:. C I/)- Zip Code: `iZt qy ',. Escrow Phone: % j Ll 3-12 c�L1CJU
Email Report to: T i — C
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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 I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date:
OR
Owner/Agent's signature to decline inspection: 1/t Dater
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Account # 01050504-521040 _________________ Mnka Oharkc nminhla to- rITV nr n/ruionor araru
Building Division\forms\RBR_7-1-21