HomeMy WebLinkAboutR2022-0017 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
�l OA�1�/�O� I�I,1Qo Civic Center Drive I P.O. Box 1768 ( Newport Beach, CA92658-8915
RBR# 2 G(� l '[ www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fee:-$19B.o0- Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $131.00 or Incomplete will be returned
Please type or print and complete all information
#of Units: Address:AJC ?JCfth'512FNewport Beach; State: —�Zip:9'(g
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OwnerAddress: ®/.S 3
State: CA Lip"Code:
Owner's Authorized Agent: s- 6ys S cNL0 VD6VL.
Agent Address: a 10 /17EnI D off i
Zip Code: �a,d63
City: r/EW }�JL'�-•E./pC%l.............
Home Phone: ;jT.7 rf.'7....7 / 6. &Y
Work Phone: L7/o - 3os- 3.2 t/ if
City: zrprvcl✓o 7�i�/a3 (/�i065
State: CA i Zip Code: Agent Email Address:
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Escrow Company:/S.s/.D�/ (��RY �Se/LarJ Escrow#: s�o�o3—KSTJ
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Escrow Address: (�,$�,;>, d,�q ✓-�1'Amzra4 , 395 city:
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State:�ir A Zip Code: Escrow Phone:53(�-7 �g'f
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Email Report to:
For Inspection call (Name):• ��� Direct Phone: ti/A
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections ofthe property listed above. I 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:
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Owner/Agent's signature todecllne inspection: C ��TU j�_ �-�—
��`!lii���u��� 33ee�- Date: O
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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