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V u I 00 Civic Center Drive I P.O. beeachca,gov 1Newport949) 64 -3200 CA92658-1,4Y'f�
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Application for Report of Residential Building Reco s °j7'of
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#of Units: L! 1 Address: 4� �j/ i'(ljn�(! C�i��j�n C1ty: Newporc9each State: [CA]Zip:
Property Ownerl WL*W �lr ojh\ho j, 6nAht Mo ,(,,(()W, Zip Code:
Owner Address: " City:
State: Zip Code: .� Home Phone:
Owner's Authorized Agent:
Agent Address: City:
State: E:7�7-- Zip Code: Agent Email Address:
Work Phone:
Escrow Company: ENI' f Aonr\ :(+�, Escrow #: (�t7cj��
Escrow Address: I) w N f l,Vj RI L l wky- tJn . 60 City:v O j J 1/1: ,y ,(�V\
Stater Zip Code: � ( U Escrow Phone: Ci Lft — (-.p
Email Report to:
For Inspection call fName): Direct Phone: E J
CONSENT To INSPECT !FORM MU$T BE SIGNED & DATED BELOW)
Account#01050504-521040.................Make checks payable to; CIrV OF NEWPORT BEACH
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