HomeMy WebLinkAboutR2022-0170 - Permit ApplicationCzf,CE1ft gY
COMMUNITY
Printi orm City of Newport Beach DEVELOPMENT
COMMUNITY DEVELOPMENT DEPARTMENT MAR 3 0 2022
BUILDING DIVISION
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100 Civic Center Drive P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# 2-010 www.newportbeachca.gov 1 (949) 644-3200 CITY OF
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Application for Report of Residential Building RecorMORT BEP",
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: 11019 I:) M' I1>� fib U L ik 5WCity: Newport Beach State: CA Zip: i -.b(� D
Property Owner: -i Rom N6 M eL H 1�-I\j a Zip Code: Fr %_a.�
Owner Address-: 1 j DI N 131�v.� I a E Goll L' :} 50"i City: I N.0 W po R—( o { q-6 V
State: CA Zip Code: cP L(,L-p Home Phone: 131 G Zy 2-
Owner's Authorized Agent: ( Work Phone: � ., j
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Agent Address: (c,'i-V) VE iwo P*. 6L Ilii #4,D0 city:y di Est M.A'N 4�A I �a
State: LT` v Zip Code; `3 Iq D� Agent. Email Address:
Escrow Company:' +
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0 , TIT L E �}, jj. �Escroww #:18- r( L) H i L -" D 0
Escrow Address:I.-�1.V�..��UPRitti+%-{�..-IJ((i.�%,�..-'11�I.I City:I (J(11�Lt%l)li
State:) V� Zip Code: -i I U 1'. Escrow Phone: �) � -�T L.'� .y l'}(}?i
Email Report to:F—'bRV 10 , PRLi=(Z 1`40 L
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For Inspection call (Name):
Direct Phone:
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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 orZoning
violations are discovered I will be responsibleto c rrectsaidviolations.
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owner/Agent's signaINS @gthorizertirl;p�gsiipn: Date:
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Owner/Agent's signature to decline inspection: /�l'M`,��.. Date:
Account # 01050504-521040 .................Make checks payable to: al r or tvtwvuru veFl6n
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