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HomeMy WebLinkAboutR2021-0839 - Permit Application (2)Print Form �-X47,1-obi RBR# 3I City of Newport Beach COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915 www.newportbeachca.gov 1 (949) 644-3200 for Report of Residential ismiaing rtecoras 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: Fj Address: 1 l 4 ©r` Li) I �J'C_, City: Newport Beach, state: F-1 Zip:7j� S Property Owner. d UG n P, ^) -e._ C,- W 0j a Zip Code: �— owner Address: I i .A4 01 r) 1\ knCA 1; . City: 5 d b I s PO State:F Zip Code: I Ci3ya5 Home Phone: 1 �d.�' - -14y- 3 J 4 b Owner's Authorized Agent: I LO (L� (j\ � Work Phone: f �{ j . I_0 qo Agent Address: h U`1 I •-eti�-k dC) City: 44 U 1� J Gly State: F-77— Zip Code:Fa U -1 v Agent Email Address: ( L --c- Fbq l ke z 1h ry A I • co rv� Escrow Company: WA Lh",\y �" C)/\X- S CN(o �Aj Escrow #! _ Escrow Address: City: U (+\,S� c7 - State:— Zip Code: l).V q-61 Escrow Phone: Email Report to: I M( --v a q d VG n}-�'. 5.,�� /� �.� 5 [may- dam . (JA N\. For Inspection call (Name): 11 --- 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: Owner/Agent'ss nature to decline inspectionr--fit �P z--� Date: Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORTBEACH