HomeMy WebLinkAboutR2024-0072 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED BY
BUILDING DIVISION COMMUNITY
DEVELOPMENT
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658,gg,�y,
RBR# L{ �Q L www.newportbeachca.gov 1 (949) 644-3200 T G 9 2024
Application for Report of Residential BuildingRecord C RTOBE
�IEVJPORT BEACH
Application Fee: - $208.00
(For All Residential Buildings) Notice:
Reinspection Fees 138.00 Applications with insufficient fee payment
or incomplete will be returned
Please type Or print and Complete all Information
# of Units: 5 Address: F4
�� ( �Ya,Yti _i - City: Newport Beach State: CA. Zip:
ll
Property Owner: _ U1 i
Zip Code: F_—
Owner Address: I City: -
State. CA Zip Code:—; Home Phone: j
Owner's Authorized Agent: Work Phone:
VA n__ F I u
Agent Address: --- — - -
City: j
State: F — Zip Code: F
i
- Agent Email Address:
Escrow Company:C� I' -- Escrow #: � LLJl
Escrow Address: -
State: i CI .p.}. Zip Code: '� (,h/ r ��
1 c .�. C (� Escrow Phone: ) ' �.
Email Report to: _ _. � �l�l-' hS,.JC/i�(A�,�•_ 1.��\ -- ___. ..--..
For Inspection call (Name):
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 correctsaid violations.
Owner/Agent's signature to authorize inspection:
Date:
R
Owner/Agent's signature to decline
- )/� Date:
Account It 01050504-521040 .................Make checks payable to: CITY OFNEWPORT BEACH
Building Division\Porms\flBR 115-22