HomeMy WebLinkAboutR2022-0027 - Permit ApplicationPrint Form
City of Newport Beach ,i.C5Iveo er
COMMUNITY DEVELOPMENT DEPARTMENT COMMUNITY
BUILDING DIVISION DEVEI.OPMENT
100 Civic Center Drive I P.O. Box 1768 [ Newport Beach, CA92658-8915
t (6 www.newportbeachca.gov 1 (949) 644-3200 JAN 19 2022
Application for Report of Residential Building ReCOrdSCITYOF
Application Fee: $198.00 - ..........:Notice: _ J� ORT SSI"'
(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.01 Address: ?I j City: NewportBeach State: CA Zip:_I
Zip Code:
Owner Address:
State: CA
Zip Code: F
City:
Home Phone.
Owner's Authorized Agent: Work Phone:
Agent Address: City:
State: F Zip Code: F Agent Email Address:
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Email Report to: Ter 1....._�_. Lo—,, ?s�..tir d t f�A �j n - ..__ ...._. _
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For Inspection call (Name): 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:
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Owner/Agent's signature to decline inspection: — Date -1d; 2,2---
Account
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Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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