HomeMy WebLinkAboutR2022-0167 - Permit ApplicationPrint.Form
RBR#
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENTGI 1VED 6y.
BUILDING DIVISION COMMUNITY
100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA 92658-dMLOPMENT
www.newportbeachca.gov (949) 644-3200 MAR 3 0 2022
mppimaiion Tor Keport oT Kesiaenrial tfullaing Kecoras
Application Fee: - $198.00 Notice: 4
u
(For All Residential Buildings) Applications with insuffic a eErlepayment
Reinspection'Fee $ 231.00 or incomplete will be returned
Please type or print and complete all information
# of Units: I / Address: 3 V City: Newport Beach j State: CA Zip:fl
Property Owner: C/HfQ C 7�(% ate'% 3 q � A I
Ala J-�.Va [�lxl(� t/ ✓J
Owner Address: 3
r/aState: CA Zip Code:
t/ 2 Zsovi\j Zip Code:
City: III
Home Phone: f `Jl 1-11 11-1 14-� 0 l
Owner's Authorized Agent: LAJ 1 S NCi Work Phone: 17:�
Agent Address: _ V� l" City: / / l p\) KOCH
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State: —! Zip Code: Agent Email Address: i�A civ
Escrow Company: �j fY/ j {� Sp 2 L� Escrow #:: �� _
Escrow Address: I ( 61/.. �u1'�)�J 5LUM1/�-P/v✓.. City: Ll Y\/r) 1plj� {� 6AC I
State: e I Zip Code: - l� X Escrow Phone: TI V- nJW --0
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 Iwill beresponsible tocorrg�t said violations.
fIn CTION
Owner/Agent's signature to authorize inspection: ®Fri rA'Cry Date:
OR
Owner/Agent's signature to decline inspectio G� t/V�X/Qr Date: --,)
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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