HomeMy WebLinkAboutR2023-0420 - Permit ApplicationPrint Fo m City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION MAY 112023
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
# (L` Lt - OLA2,0 www.newportbeachca.gov 1 (949) 644-3200 CITY OF
Application for Report of Residential Building Records NEWPORTaFACH
Application Fee: - $202.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $ 134.00 or incomplete will be returned
Please tvoe or print and comalete all information
# of Units: I ' Address: 11500 Lincoln Lane City: Newport Beach State: CA zip: 92660
Propertyowner: Raff Revocable Trust Zip Code: F
Owner Address: City:
State: CA Zip Code: Home Phone:
Owner's Authorized Agent:
Agent Address:
State:
Zip Code:
Escrow Company: I Freedom Escrow
City:
Agent Email Address:
Escrow Address: 11200 Newport Center Dr., Suite 180
State: FcA Zip Code:F 92660
Email Report to: I mm@freedomescrow.com
For Inspection call (Name): I N/A
Work Phone:
Escrow #:1055812-MM
City: I Newport Beach
Escrow Phone: I (949) 644-3939
Direct Phone:
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 correct said violations.
Owner/Agent's signatureto authorize inspection: Date:
OR
Owner/Agent's signatureto decline //,n„c A ryT,v rjyT- Date: Oa�, -I (- Z 3
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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