HomeMy WebLinkAboutR2023-0236 - Permit ApplicationRECEIVED BY
COMMUNITY
DEVELOPMENT
Print Form City of Newport Beach MAR 2 42023
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION CITYOF
100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA92658-8915t4EWPORT8EAW
xil (Z 2023 'oz5G www.newpoi-tbeachca.gov (949) 644-3200
Application for Report of Residential Building Records
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
# of Units: F Address: 34 a a- C>r City: Newport Beach State: CA Zip: F2Z 6 2 S
PropertyOwner: d"fayl /Y1o7� a"rl Zip Code: `)`LGrj3
Owner Address: 1 2-r-T43 HiJJ - pp
u'1 I rdtiA city:
State: CA Zip Code: 92 G 63 Home Phone: 3 \ O " %,k 5r 3
Owner's Authorized Agent:
Agent Address:
State: F Zip Code: F—
City:
Agent Email Address:
Work Phone:
Escrow Company: I F I t� LI ) 'V Vt.' IOKa I I'H.e (-oM ty Escrow #: 0032) g' 9 s o o\�
Escrow Address: 13 oo Dove St, 3YJ Fl oo r City: / New Po w'L /.i e^z k
State: C A zip Code: i 2 9G D Escrow Phone: 1 9 L4 9 -'4 n - noo
Email Report to:I -tLe--(e AV. Com
For Inspection call (Name): I 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 signature to authorize inspection: Date:^
OR
Owner/Agent's signatureto decline Date: I 3✓2y/ 2 n �3
Account # 010SO504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Bui1ding_0ivs-AFarms\RBR_61522