HomeMy WebLinkAboutR2021-0232 - MiscIN 14�1
nnt:F�rm=: City of Newport Beach'
COMMUNITY DEVELOPMENT DEPARTMENT
�n BUILDING DIVISION
�W?I, o/i2 1 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
t# t��t/ G J L .www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Ippllcatibn-Fee• . $ 194. 00
For:AllResidential Buildings)
leinspection Fee ,$129.Do"
of Units: ❑ Address:
operty
,vner Address:
NbUI
.. APro lications•with'•insufficient fee payment
or incoinplete,will6e retuned' .
Please type Or print and cOMPlete all information
ate: CA Zip Code:.
City: Newport Beach State: CA Zip:l i
I Zip Code: RJ/7
, � 1
City: t ����cam/
Home Phone: �'7
wner's Authorized Agent: n Work Phone:
;ent Address:
r�—
ate: l �J Zip Code:
S� J Agent Email Address:
.crow Company:
scrow Address:
tate: E J Zip Code:
mail Report to: /',enZ4
Escrow#: j17 1 f:
Escrow Phone:
or Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections.and re=inspectio'n's of the,property.liS
violations are'discovereii l will be resporrsible to correctsaid
Owner/Agent's signature to authorize Inspection:
OR.
Owner/Agent's signature to decline inspection:
Date:
Account # 01050504-521046 .................Make checks payable to: CITY OF NEWPORT BEACH
Iltling Dlelslon\Foams\pgft 93g-1g