HomeMy WebLinkAboutR2022-0315 - Permits (2)yaCMVED
City of Newport Beach CDMMuNITYP
COMMUwry DEVELDPMENT DEPARTMENT )EVEWPA4EMT
BUILDING DrVISION JU 2
g7� 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8 faQ ZQ22
RBR# i�J " OZZ -N-!2 www.newportbsachca.gov 1 (949) 644-3200
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Application for Report of Residential Building Rec*Os
orrucvmplet'e will:6e;iieivrned:
Please type or print and complete all information
# of Units: Ef I Address: 2q Q y 3 ro 5-e + 1 Llty Newport Beach State: CA Zip: TZ -6 3
Property
Zip Code:. (v6 ?j
Owner Address: Ll YO 51�City' "?a r+- 3e�--C k
State: CA Zip Code: 6 G 3 Home Phone:
Owner's Authorized Agent: I we 1�m SO„
Agent Address: '139 1 fl
WorlkPhone: (qyq 278 7370
City: jv O'rir- %-eQC k
State: C-A Zip Code: q:. &-0 Agent Email Address: �C del, aV� O✓t�'Q�''I SS. iwt
Escrow Company: M Escrow # LCWN a- A 6-1-oq7l
Escrow Address: J Cty: 1 LKA&W-1- r-
State: Zip Code: lIU / el /1 t 11 Escrow Phone: �G%yq� 2-7-0 100-2-0
Email Report to: �{NI [��=�r+v"PjkeSGt'pW • Cps
For Inspection call (Name): —� Direct Phone:
CDNSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELDW)
rzutlinrze Inspectrons.and re=iiaspectionsaf'the property listed above. I understarid-tFrat.rf Building ortonFng.
vrolationsare discovered.] wiilbbe:res'ponsihl''eto aorrectsa d viblations. n
Dwner/Agent'signature•to•authanFzei,nspectron: INS( EQ.Tj, AN
DR DECLINED
Dwner/ti4g'eaC'ssigrtature-to deciroe.inspectioc�: �� j ate:: '2j�/ZppZZ�
Account # 01050504-521D40 .................Make checks payable to: CITY OF NEWPORT BEACH
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