HomeMy WebLinkAboutR2022-0388 - PermitsPrint Form City of Newport Beach ��CSIVED Sy.
COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA92658-,&1% 5 2022
RBR# 17Wzz—Effi ' www.newportbeachca.gov 1 (949) 644-3200
CITY Of -
Application for Report of Residential Building Records r,
Application Fee: - $202.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $134.00 or incomplete will be returned
Please type or print and complete all information
It of Units. F/ ! Address: %S p Su Y'T V�P,GO [a {!!Q City: Newport Beach State: CA lip: 9 z & Z- 5
PropertyOwner: //
14cfhv ki p� L PO fi oG Tt701((e /� �Zip 2 55
Code: g
Owner Address. 35V 0_ _ �Y "%r f ✓I B (/� j4 � ',, City: .. /1eu),l d-,e // -
State: CA Zip Code: 4T& 1 S
Owner's Authorized Agent: �Dri f io-fon
Agent Address: r 6 VX 99 2 -t q q City:
State: WF Zip Code: 25'89', Agent Email Address:
Home Phone: I '95-/
Work Phone: y -/ 2 L/`/' / T 7 9
TPirn e,L' u. %
Gol�_�es77'�h��a.o/court'
Escrow Company: a" PAY 1 u /I S �S tz to Escrow #:
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Escrow Address: /'&23 �n'� U`d City: 7
State: 15 Zip Code: R Z �� Escrow Phone: 3 3 I. 7 '�DO
Email Report to: I doe 1 o / v� 9 e PieSCgiO w • co _
For Inspection call (Name): TA- ftl jn� ` -n cl ie Direct Phone: 9�j • 25 2. c` ?
rCOO `NSENT 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. INSPECTION
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Owner/Agent's signature to authorize inspection: DECL'1 ED
OR
Owner/Agent's signature todecline6;ih Date: '2-7- ZZ
Account # 01050504-521040 .................Make checks payable to: CITY OFNEWPORT BEACH
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