HomeMy WebLinkAboutR2021-0814 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION " r
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915 v r..
RBR# www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fee: - $198.00 Notice: i_\, Or
(For AIIResidentiai Buildings) Applications with insufficient feepayment
Reinspection Fee $131.00 or incomplete will be returned i
Please t tre or print and complete all information,
#ofUnits: 1 Address �(y�Q 7uf1�4�1 T �. 5z City: [Ne wport B.each State: CA Zip: 9z�Zs
Property Owner:QG � G aoAty-,,r j�i�� C Yt.- Zip Code: q Z(yQ 3
Owner Address: 23 Op a( s ! City:
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State: CA Zip Code:1942 Nome Phone q 2t3 tCz
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Owner's Authorized Agent: G on0. z 4m6 Work Phone: 949 ' l % ." Zgoz
Agent Address: qqQ V City:
State: C Zip Code: Q'2GI I -� /�I r
_ _� Agent Email Address: Ir14. 1.y/+1lOOitq.l�j,44-4—�(r1G./t GQ.t",h
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Escrow Company: �.� ^ C�Gir' ..,.. 5L6' .._.-.-....---- ----' Escrow # I"f.__- L -Z'S -G w%`..'
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Escrow Address:12$ZO'Z Cabo-� 205
State: Zip Code
City: J La Ju.na N; uc.
Escrow Phone:
Email Report to: CLl��lL�q,QlrlDd5e5�Cpi.1~p(�i.. �
For Inspection call (Name): •) Direct Phone: I I�\li�
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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 orZoning
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: ,R � g Date: 12 / 01 —/2 —1
Account N U1lI5USU4-5Z1U4D .................Make checks payable to: CITY OF NEWPORT BEACH
Building Dwidon\Fmms\MR 7-1-31