HomeMy WebLinkAboutR2022-0023 - Permit Application"ko-CEIV80 0k
COMMUNITY
City of Newport Beach DEVELOPMENT
COMMUNITY DEVELOPMENT DEPARTMENT JAN 18 2022
BUILDING DIVISION
�n �,7� 6�100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915 CITY of
RBR# IN V www,newportbeachGa.gov 1 (949) 644-3200URT 60p"
Application for Report of Residential ounding Kecoras
Application Fee: - $198.00 Notice:
jFor AilResidential Buildings) Applications with insuff chant fee payment
ReinspectlonFee $131.00 or incomplete will be returned
Please type or print and complete all Information / (�/J�
#of Units; Address: City: NewportBeaeh State: r,Zip:r-<V' ""til""
PropertyOwner:I----`f A[�t .1.� .. Zip Code:
—!
Owner Address: �%`. City
State! Zip Code; �Y.' Home Phone: �—
�,�G Cc J �� • _ .. Work Phone:
-Atitherit• ``-�--
City:
.l�!ewn./� ll�..-h. ..._......
State; Zip Code: T�W?,- _ Ager& Email Address: ��, rc9�f Lc- . c o
Escrow Company:Escrow #:I
Escrow Address: TicorTitle Company City:
1500QuaIIStreeG3 -Floor-Newportgeech;eA 92660
1 -28 ne 949.80943617 Fax;
State: 7 1�- Escrow Phane
7 -
Email Report to:
For Inspection call (Name):
+ Direct Phone: I
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOWI
I authorize Inspections and rerinspections of the property listed above, l understand that if Building or Zoning
violations are discovered l will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
Date;
OR
Owner/Agent's signature to decline inspection: „i''j�� Date;
BWI41nL@IVISIo14Fo,mt\R@RJ]•ZS
Account # 01050504-521040 ................. Make checks payable to., CITY OFNEWPORT BEACH