HomeMy WebLinkAboutR2023-0822 - Permit ApplicationPrint Form
City of Newport Beach RECEIVED BY
COMMUNITY DEVELOPMENT DEPARTMENT COMMUNITY
DEVELOPMENT
BUILDING DIVISION
;;77 --�� 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658W1EO 6 2023
RBR#P..-p��� www.newportbeachca.gov 1 (949) 644-3200
CITY OF
Application for Report of Residential Building Record§EwPORTBEACH
Application Fee: - $202.00 Notice:
(For AIIResidential 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: � Address: I I vl5 I Ave, City: Newport Beach State: CA Zip: TZ0
PropertyOwner] R1.L.)VAR, /
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Owner Address: A,5(jO Wrporl`lJ PI. mod\ I
State: CA T Zip Code: Fn 5
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Zip Code: I S
City: or) 4t Pa( I c
Home Phone: 8I F - 6D I
Owner's Authorized Agent: I L1sa, nu6-1 Work Phone: JVJ��S/'a-�30
Agent Address:
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State: CA
Zip Code: ZIObO
Agent Email Address:
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Escrow Company: Wes�fna U-RL y C Cr'oo Escrow#: 1 2-6 - 7 3 2,°-
Escrow Address:
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State:
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Zip Code:
F96i I )
Email Report to: I - Wts AWpZSCnw , COvn
For Inspection call (Name): I Lf Scz 4n G &-)
City: GZwood
Escrow Phone: 5� - 8 G 6 -q Lq q
Direct Phone: I 5ba„-5 / a- I.4U l
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 correctsaid violations.
Owner/Agent's signatureto authorize inspection: VjGg� G iJ�, Date: 9.5-23
Owner/Agent's signature to decline
Date:
Buil&ngDivisian\Forms\RBR_6-15-22
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH