HomeMy WebLinkAboutR2023-0990 - Permit ApplicationDocuSign Envelope ID: 66732EA8-1 B24-4152-94F4-58A9902E3BA7
Print Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
n 6(
0
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# www.newportbeachce.govi(949)644-3200
Application for Report of Residential Building Records
Application Fee: - $208.00 - Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $138.00 or incomplete will be returned
Please type or print and complete all information
#of Units: F Address: �' �(,� C,r p5 t,4 l-G L�l'1 tft'l_ City: Newport Beach State: Zip: L (F.; C
3 z �':'_
PropertyOwner: 1 ' (' -L, )�1•` - Zi Code: (_
L-GI,"- ..�--'�Gl:l j Yl (. (�S ✓ _ t7 p _ _!
Owner Address:' C City: LV' 7 C LT
�I ✓..� r!jY�tiYiy`���� ��I Vim'. �- ---
State: CA Zip Code: I�� ;r �� u Home Phone: Jj.(' ��.e c
Owner's Authorized Agent: bCAv l (( C.-? ' Gvf'a
Agent Address: jlhr o�.U'eT,-.
Work Phone: I t11 G1, � I." ! 2"0 7 "....
State: IU-- Zip Code: j 'tl',i� _ Agent Email Address: II 11 mow) T-
Escrow Company: 1�7 / +vl.. �l`.G .( .,ice( . Escrow#: FIT 7V7V-v
Escrow Address: GVt IJ 1 �7 C1G{T': i 1.�ti l �t. j L City: c i l
- J '%/ v , r
State: C� Zip Code: C1 �-"A Escrow Phone: / d 3
Email Report to:
� C✓
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 correct said violations.
Owner/Agent's signatureto authorize inspection: Date:
OR
DocuBignetl by:
11 14/2023
Owner/Agent's signatureto decline `� ���� �� Dater—
_ E49BC871AB9349E_-
Account # 01050504-521040.................Make checks payable to: CITY of NtWYUH/ ner4un
BuiIdl�Mvlalon\Farms\RBR 6-15-11