HomeMy WebLinkAboutR2022-0140 - Permit Application�GEIVEU BY
COMMUNITY
Pfinl Forrn City of Newport Beach DEVELOPMENh
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
c Center Drive I P.O. Box 1768 [Newport beach,
�Ih
www.newportbeachca.gov 1 (949) 644-3200
MAR 14 2022
CA92658-8915
CITY OF
Application for Report of Residential Buildine RecordsVPnc,T O�IGt
Application Fee, -$198.00 Notice:
(For All Resident ial Buildings) Applications with insufficient fee payment
Reinspection Fee $131.00 or incomplete will be returned
Please type or print and complete all information
ll of Units: ! Address:Cit
Y• Newport Beach State: CA Zip: 9CZd a�
r' �r ,j- Lam.
Property owner: r/ G(.lr� L, j (6;7 1.� �r ��s! ),Yl i, � � �. /� Zip Code: j, 6� J .
Ovmcr Address: f % �U .i �.'.r l�e'r(' av-� • env' :j Cl1J-Ll�lee (-l-�t---
1 I��-...fir
Slate: f'A Lt Zip Code: �/CItlDT Home Phone /�'
Owner's Authorized Agent: l (CL.le I e Uan cle L%1i/('l� Work Phone: �.1 L/ �3 i Z 1,
Agent Address: ,•G3G C -C/111\1./, o 44( NO,,) -24,,266 City: ,�/%n - (),v)jt J(0
State: /, Zip Code: ^ 7 3 Agent Email Address: L lJ r t
Escrow Company: !I r'.�r� Escrow it:
EscrowAddress: �'L Yr�/ 13C �)`t� ,.�✓ •City:)ffjS nn
State: F 1, ' I Zip Code: Fi7? K Escrow Phone:
Email Report to: I !-L r/ & (>L; r� ere ( rvL j • ai ,�y1
For Inspection call (Name):Vale (e- 211aer Direct Phone: / � (1•.- �JjU •�)/rJ.' /
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 Iwill beiesponsibletocorrect said violations.
Owner/Agent'ssignature to authorize inspection: Dale: �rt, \.,1 �, r�r.•%\I (t-.�'-�
_. - ---�-
OR
Owner/Agent's signature to decline inspection:
Date:
Account 1101050504-523040 ................. Make checks payable to: CITY OF NEWPORTBEACH