HomeMy WebLinkAboutR2021-0773 - Permits$-�Pcfr t'Form;i;
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City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
Z��G113100 Civic Center Drive 1 P.Q. Box 1768 1 Newport Beach, CA92658-8915
RBR# ` www.newporibeachca.gov 1 (949) W-3200
Application for Report of Residential Building Records
Application Pee: - $198.00 Ham
(For All Residential Buildings) Appllcatlons with .insufficient fee payment
Reinspectlon Fee $131.00 or incomplete wRl be returned
Please type or print and complete all Information
#afUnIts: EllAddress; �,-Q� �t�• S lia�� 4•y���i City: Newport Beach,) State: �Zlp:� ZG� j
Property Owner: iCW>1 i-Ttn{t. L.2 � I,yv� 10, t-4[! Zip Code: 6L6
owner Address: l6Ql t[q Slot Clty: �.uJ d✓'r �j�ol._
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State: CA^-.--....._.....__.�,.._..J Zip Code: �ZGs l_._i Home Phone::;, l,_..3 A -a ___3 4-
Owner's Authorized Age= µ.avtl Work Phone: -
AgentAddress: ! 5"'�"5 / o�rza G,,,..�t„c �- 52< .�# 7.2 City: ff oez fivU^'kt-S •�P•' i
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State, Zip Code: Agent Email Address:
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Escrow Company:
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IJ �� ,� IC �SClrb Li Escrow #:..._..___... J
Escrow Address: _.. .... .. ...._. r ^ti C ti_._..__..._....____......__._--- -City: IAA Q.B t-MA, n.:&f-e.(— _._ ..__�._..._-....
State:%, _-.,J Zip Code: -_�,i Escrow Phone:
Emall Report to: �,,.� an •{-y�tN1 .y'�"�- . is Lr c 40 _ .0 wl _.,.._........�
For inspection call jName): [ r eq v 4J?�� Wj Dfrect Phone:
CONSENT TO IN5pECT!FORM MUST BE j,NED&, DATED BELOW)
)authorize inspections and re -Inspections of the property Ifsted above, I understand that if Building or Zoning
violations are discoveredIvAlberesponsibletocorredsaIdviolations, .. ,
Owner/Agent'sslghaturatoauthorizelnspection:.Date:
OR
Owner/Agent'ssigriatuieto declinelnspectlon: �•J'' �t^� _ Date: t( IT, �,,,� I
Accaunt # 01050504.521040.................Make checks payable to: CITI'OPWINPORTBEACH
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