HomeMy WebLinkAboutR2021-0232 - Permit Application (3)R.22I - C)232
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F?rn x e City of Newport Beach'
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
tpplidatlonf194.00 Nat)ce
FoCpI6Resid'ential Buildings) ' : " Applications with•insufficient fee payment"
leinspection Fee.$129.00 - or incomplete:wi11 be returned'
Please type or print and complete all Information
of Units: ❑Address: City: Newport Beach State: CA Zip:]]
'operty Owner: �~ , '%rt� Zip Code:
.vner Address: I / / C�� L4lC(%I City' I ! ll 05
ate: CA Zip Code: S Home Phone:
;•
wner's Authorized Agent: I /�1)")77�. ���S �nWork Phone:
gent Address: '!-1r>.f Lei amity:
ate: r Zip Code: Agent Email Address:
crowCompany:
scrow Address:
tateo =
mail Report to: ��eh
] Escrow#: VJ�—=
Escrow Phone: / O �6n
or Inspection call (Name): Direct Phone: E
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspection's of the,property listed;abovezhyndeFstand that if Building or Zoning
violations are discovered l will be responsible to correct said vloiations
Owner/Agent'ssignaturetoauthorize Inspection: - - Date:
Owner/Agent's signature to decline inspection:
OR.
Date: J
i1d1ng_Olvh1on\Fams\Ra 9-is-is
Account # 01050504-521040 .................Make checks Payable to: CITY OF NEWPORT BEACH