HomeMy WebLinkAboutR2022-0213 - Permits (2)DocuSign Envelope ID: OFE884EB-BC2F4EAF-8051-A47BC9E40D18
Print Form City of Newport Beach ,.ScEIVED ey
COMMUNITY DEVELOPMENT DEPARTMENT COMMUNITY
BUILDING DIVISION DEVELOPMENT
100 Civic Center Drive ( P.O. Box 1768 1 Newport Beach, CA92658-8915APR 8 Z�Zz
ItBR#?,k'I Z 2 /�211% www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records CITYOF
Application Fee: - $198.00 Notice: T 6EPC'�
(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: F Address' Z` O-7 Gc, 4h C',Oe _ ,.... _ City: Newport Beach State: CA Zip: E� CJ
Property Owner:
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Zip Code: "1) A
Owner Address:
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State:
CA Zip Code: q1 vto
Home Phone:
1 949-922-5942
Owner's Authorized Agent: De-S lie _._.'//�,�w,'��.. _..
W/orkk Phone; �i 300-q £DL4G
Agent Address:
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State: G(�- _ Zip Code: qX(, --7 Agent Email Address:
f2, 1We V CA VA @ 3MC41.. (CAM _.
Escrow Company: �rWp F-C-ra- j
Escrow #:
Escrow Address:
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State:
G� Zip Code:
Escrow Phone:
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Email Report to:
For Inspection call (Name): �P ve Rtn (n 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 I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspectioqIN-SiR EC i IC�,l Date:I
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Owner/Agent'ssignatureto decline inspection: �I,u.yt5{'b�Lt.V' QStU.V' Date: 4/18/2022
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Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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