HomeMy WebLinkAboutR2022-0185 - Permit ApplicationDocuSign Envelope ID: E9DEB5D2-CD4C-4EF5-9348-EF7D6B932420
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# www.newporibeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fee: - $198.00 Notice:
(For All Residential Buildings) Applications with insufflcientfee payment
Reinspectlon Fee $131.00 - or incomplete will be returned
Please type or print and complete all information
# of Units: Address. Ci),i l t . , i.,,, City: Newport Beach State: CAt-
Property Owner°r Zip Code_
Owner Address:1Ltsi'?,Il;}-t'
State:F Zip Codew;`_i^;�
Home Phone
s
Owner's Authorized Agent: t i,� ` s t Work Phone:
g f t'r �..'.. _. et V ia..l � . ................. i !
Agent Address . lz t i,- " j-,iCity:ua� o `mot '
State: f1 Zip Code I�-�. ?f' ,f,-�,• Agent Email Address: „i.�, ` W 1
_ - ._.
Escrow Company:¢�.vV+i't:,....: y '''.� Escrow # a
is"i lc,. \7v{ticlti ,�. rACity: fiAyli>'l �x't�it
Escrow Address: t �'
State: �— u Zip Code �.. '�'" Escrow Phone: i ..- •'; 1
C �� p %tip _�I art_
Email Report to: lrA` 1�At,A
s %.
For Inspection call (Name): - 4�
l,•i
Direct Phone:I' l<]
! ..
CONSENT TO INSPECT (FORM MUST BE SIGNED R: DATED BELOW)
I authorize inspectionsand re -inspections of the property listed above. I understandthat If Building or Zoning
violations are discovered I will be responsible to correct said violations.
/—DacuSigned by:
Owner/Agent's signature to authorize inspection: - 44— 0..vri.
Owner/Agent's signature to decline Inspection:
m
Date:l 3/30/2022
Date:
Account # 01050504-521040 ... ......... .... Make checks payable to: CITY OF NEWPORT BEACH
gullClry Dwizian\Fprtns{P80.„7-121