HomeMy WebLinkAboutR2022-0354 - PermitsPrint Form
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
�100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBRIf �/J 3 www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fee:-$202.00 Notice:
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $134.00 or incomplete will be returned
Please type Or print and complete all information
# of Units: Address: l� City: Newport Beach i State. CA '..Zip:
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Property Owner: J Zi Code:
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Owner Address: �'rS'%f'7%y�LXG�cd'f'/ City:
State: CA _ _ _ Zip Code:t�S"� Home Phone:
Owner's Authorized Agent: Work Phone:
Agent Address: city:LAV - _ v4
State: Zip Code: G/ Agent Email Address:
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Escrow Company: �/ Escrow #:
Escrow Address: /� /� Cit
State: F—&�— Zip Code:`�i �L/; Escrow
Email Report to: , op
For Inspection call (Name): i.�'r - Direct Phone: ��� �� 52
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 correctsaid violations.
Owner/Agent's signature to authorize inspection:
Owner/Agent's signature to decline
INSPEgTI:A.
DEGUNE
Date: 1 — 11
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Bu dm1 Division\Forms\RBR 615-22