HomeMy WebLinkAboutR2022-0148 - Permit ApplicationPrtrit'Form ! City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT . A-D4y
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-891(9)WAUNrry
RBR#Y/ 1 www.newportbeachca.gov (949) 644-3200
Application for Report of Residential Building Records
Application Fee: - $198.00CC\,i;wr'I��IENT
Notice: '--'?,
For All Residential Buildings) �
( s g) Applications with insuffici'#ptlfgg, p�yr$ent
Reinspection Fee $131.00 or incomplete will be returner)
Please type or print and complete all information
#ofUnits: 1 12SJ Address: %r�Y1,Qi4� City: NewportBeach State:Zip:
Property Owner:[ -r Zip Code:
F-9
----- ------
Owner Address: 1+610 City:
State: CA— -- Zip Code: jHome Phone;'_�f_-1-_�7
Owner's Authorized Agent: Work Phone:
Agent Address: �_ ----- ----J City: —------------ -----------
State: F777 Zip Code: J Agent Email Address:
Escrow Company:#:
Escrow
E G 967-71- --i--------1
Escrow Address: City: - J
State: _ C Zip Code F Escrow Phone:
Email Report to:
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 violiNISP
CI ION
Owner/Agent's signature to authorize inspection: DECLINED Date:l
OR
signature to decline
Date:
Account # 01050504-521040 ................. Make checks payable to: CITY OF NEWPORT BEACH
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