HomeMy WebLinkAboutR2022-0172 - Permit Application�OEIV�'1�
City of Newport Beach coMMGNi70k
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION
�� _ I 100 Civic Center Drive P.O. Box 1768 Newport Beach, CA9265MRIN 2022
RBR# www.newportbeachca.gov I (949) 644-3200
CITY OF
Application for Report of Residential Building Reco s
ORT B
Application Fee: -$198.00 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: CL
City: Newport Beach ! State: CA Zip:
Property Owner: etjcc4 -- vr)_�m' j 3 (y� Zip Code: o
Owner Address: 31� City: woY+ ry '
State: CA __-_-,.--.._._.,....- .- 3 Zip Code: QoZcc(W. Home Phone: ��C�_ "1��
Owner's Authorized Agent: ,' Lcv-e,
Work Phone: (ii.�
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Agent Address:
g tom® �i �CI�_C� �� �_ _[ city:
State. TT -i Zip Code: Woc Agent Email Address: Ke-.(�VI�V'��Ct�tdW'2��IQif�l'�ut,�1L0Y ..
Escrow Company:Escrow #
11 :- M n .........
EscrowAddress: ' _ C - ,TL...141 Cit' P, i
Stater Zip Code: q� i Escrow Phone (q � q a�jl..j
Email Report to:
For Inspection call (Name): - l -q ______ ________._.., I 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 l will be responsible to correct said violations.
Owner/Agent's signature to authorize inspf N --PE l i , ; V Date:
DTCLINE
Owner/Agent's signature to decline inspection: Date:bj3)
Account It 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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