HomeMy WebLinkAboutR2024-0049 - Permit Applicationi22024 — Ooyq
DocuSign Envelope ID: C003E5F1-CA52-4045-96AA-9888030F854A 7- 03 11 12ivc/t idc
Print Form City of Newport Beach or -
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 I Newport Beach, CA92658-8915
RBR# L01_ - ooyq www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Rprnrdc
Application Fee-$208.00 Notice�-
Reinspection Fee 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: Foii1 Riverside or.
City: Newport Beach State: FCA Zip: 92660
PropertyOwner: Cary and Jaclyn Petersen 2660
Zip Code:
Owner Address: 0321 Riverside Dr. City: Newport Beach
State: 1(� Zip Code: 92660
Home Phone:1714-376-5399
Owner's Authorized Agent: Gosi a Kawczynski Work Phone: 949-230-8271
Agent Address: 27742 vista Del Lago Ste 1
City: Mission Viejo
State: FCA Zip Code: 92692 Agent Email Address: gosia@gosia4re.com
Escrow Company: I Corner Escrow
Escrow address: 27201 Puerta Real Suite 450 City:
State: FCA Zip Code: 92691
Email Report to: I eddie@cornerescrow.com
For Inspection call (Name): I Jaclyn Petersen
Escrow #: [ 05-17035-ET
Mission Viejo
Escrow Phone: 949-325-3003
Direct Phone: 1 714-376-5399
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 signature to authorize inspection: Date: F7UN�
OR
DxuSiyned by:
Owner/Agent's signature to decline 5�V, PutmAt Date: 2/6/2024
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