HomeMy WebLinkAboutR2022-0063 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
�102j -001¢ BUILDING 68 1 Newport
1 DO Civic Center Drive � P.O. Bax 1768 � Newport Beach, GA 92656-6915
RSR# www.newporthaachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Anoiicatibr F'eec:-$f Igo Notice:; -
.(ForAll9Tesideritia4.Bui{drngsJ' Appsmations+urith.iiesuFfcient•fee•payment
Rernspecfion• Fee:$,M-,DDS orfircomplet'e will:be;ueLvrnedl
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# of Units: FT Address; I Holz u+ ti- Dr V v City; Newport Beach State: CA Zip: q 62s
Property
Tap Code:. Z�ZS
Owner Address: &0 Y i/ Cty'
State; CA Zip Code: Home Phone: 'ia Z, w Ltd
Owner's Authorized Agent: 0 � y � ^ ' I Work Phone:
Agent Address: 1� • City: ovk
State: i Tip Code; `n 1�
Agent Email Address:Koo
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Email Report to:
For inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
t'aathnrize Irispectrormandre--iiispection'sof.'the property rsted above. I understarid-that if B'uiddingwZonrng.
vblationsarediscovered'I willbe:resporrsrhl'eto cprrectsaad viblations.
Owner/;4gentssignature•to a.uthor¢ze-inspectian: Date:,f
OR
Owner/AgenC'ssignaturetn deciine.inspectibn:
Account # 01050504521040 .................Make checks payable to: CITY OF NEWPORT
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