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,ACo�ro® CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDNYYY)
04/08/2019
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE,(2. TF,IIS, -
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollay(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Kimberely Kelley
NAME:
Insurance Solutions
PNONE (949) 348-7400 AA, (949) 348-2373
AIC No Ext). A/C No
License #0746539
E -MAI KimK(o�ins-solutions.com
AGORESS:
33302 Valle Rd, Suite 200
INSURERS) AFFORDING COVERAGE NAICp
INSURERA: StarNet Insurance Company 40045
San Juan Capistrano CA 92675
INSURED
INSURER B
Orange County Solar Contracting Services, Inc., DBA: Orange County
INSURER C:
Contracting Services
INSURER 0:
358 S Wheeler PI
INSURER E:
Orange CA 92869
1 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL194817448 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR
TYPE OF INSURANCE
POLICY NUMBER
MWDr V/YYYY
MWOO EXP
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS -MADE 7 OCCUR
PREMISES Ea opcunence $
MED EXP (Any one parson) $
PERSONAL&ADV INJURY $
GEN'LAGGREGATE UMITAPPLIES PER:
GENERALAGGREGATE $
POLICY ❑ jEC F7 LOC
PRODUCTS - COMP/OP AGG $
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
Ea ac dmt
BODILY INJURY (Per person) If
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Par ac d.nt) If
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE $
Pera ldent
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE If
EXCESS LIAB
CWMS-MADE
DED
RETENTION $
$
WORKERS COMPENSATION
I PER OTH -
A
AND EMPLOYERS' LIABILITY YIN
ANVCERIMEETORIPARTNDED? CUTIVE ❑
OFFICER/M In NH) EXCLUDED?
(Maneatoryln NH)
NIA
BNUWC0147315
04/08/2019
04/08/2020
STATUTE ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
DESCRIPTION OF O
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required)
PROOF OF INS
PROOF OF INS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachGa.gov 1 (949) 644-3200
X5 13wiya 5k
PV
aoo-m
SOLAR CONTRACTOR DECLARATION
Keen with Inspection card.
This form is for the Inspector to take at time of final inspection
PART 1: To be completed BEFORE PERMIT ISSUANCE
JOBSITE ADDRESS:
sUNJK j -1 -
CONTRACTOR NAME:
CONTRACTOR STATE LICENSE #>
l9 �� r 6-�- (46NT� SouW-
! d23 � 2_7
PANEL MAKE #:
PANEL
MODEL
#:
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V�'jl�rJ 33o S(�(t;
11 DECLARATION: 11
1, kH-D C� declare that the PV module make and model
(PRINT NAME)
number, quantity, and location are installed as per the approved plans. Module
manufacturer, make, model and number, fire classifications of modules, and
brackets match the approved plans for the project located at the above
referenced address within the City of Newport Beach.
(SIGNA ) (DATE)
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachca.gov 1 (949) 644-3200
SMOKE DETECTOR AND CARBON MONOXIDE
SELF -CERTIFICATION
(this certification is to be filled out by the permittee or homeowner)
Project Address:
Permit Number:
Property Owner:
X465 $unya 54
pVaOl9-OA
Licensed Contractor: _ t,)gAnj � 1pOi4f I 5oLAlL, iKL LIC #: T jc23 &ti -7
The State of California now requires that smoke and carbon monoxide detectors must be
installed in all residential buildings
California Residential Code (CRC) Section R314.1, CRC R315.2 states in part that
existing dwellings be "retrofitted with smoke detectors and carbon monoxide detectors.
CRC Section R314.3, CRC R315.3 defines required locations.
Both boxe below must be checked:
El Carbon Monoxide Alarm: On the ceiling or wall outside of each separate
sleeping area in the immediate vicinity of bedrooms or in each hallway outside of
the rooms, and each level of the dwelling. Detectors are also required in
bedrooms with gas fired appliances
❑ Smoke Alarms: Installed in each room used for sleeping purposes, outside
each sleeping area, and on each level of the dwelling unit.
Retrofitted detectors may be battery operated for buildings where no alterations are
performed on the interior. Multiple -purpose alarms (carbon monoxide and smoke alarms)
shall comply with all applicable standards and must be approved by the State Fire
Marshall. The devices must be installed per manufacturer's specifications.
1, the undersigned, hereby certify that I am the permittee or homeowner of the
project. I fu er cert' th moke alarms and carbon monoxide alarms are
present and este o fu t' nal in all the following locations:
Signature: Date: I1 2.01
NOTE: This self -certification is only used for projects to the exterior of the structure where access to the
interior of the dwelling by the City of Newport Beach Building Inspector is not achieved during the course of
construction.
Forms\SmokeDetectorandCarbonMonoxideSelfCert 88/12/16