HomeMy WebLinkAboutR2023-0199 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED BY
BUILDING DIVISION COMMUNITY
,r� 2 100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA92658-�pPMENT
Ezg ✓ (A 9 q www.newportbeachca.gov (949) 644-3200 MAR 10 ZOD
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Mppllc;a L1U11 IUI nCIJU1L U1 nCWU1=11L101 UUIIU111r, n=LUl Ua CITY OF
NEWPORT BEACH
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
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# of Units: I l Address:
City: Newport Beach State:
CA Zip:
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PropertyOwner. ��/�fl��'-C.�I� Zip Code:
Owner Address: 122 Pa `�j( �•id
State: CA Zip Code:
City: NC1/V1PU1(+ {Dk- -C 1
Home Phone: � L�6\) 2:7j}' jig 0
Owner's Authorized Agent: I )"t�� Q. Re- jrrd{{'v2
Agent Address: 1 -1, (0 Z O"Yl City:
State: 7I' Zip Code: �ZI 14 Agent Email Address:
Work Phone: )tA `ICJ -I - bb-� (
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Escrow Company: O�Z'� U\AYi J �1SoL�.(Jy/\/ KViCC_f' Escrow#: 23'
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Escrow Address: � d� N ay 11-kly 5j'. (aCity: SA
State: �� Zip Code: .f bis Escrow Phone: 1
Email Report to: ay � R C f S C `/ONN 5 C- u y'}/t v
For Inspection call (Name): I vvy\(St RyylaI AA-L
Direct Phone: I -1(vl ,- DE--1 I
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 violati s'
Owner/Agent's signature to authorize inspectio Date:
( - VR
Owner/Agent's s ignatu re to decline
Date:
3uildin�Division\Forms\RBR_6-15-22
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH