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CITY OF NEWPORT BEACH
CONINIUNITY DEVELOPNIENT 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
SOLAR CONTRACTOR DECLARATION
Keep with Inspection card.
r11•_r r_, th_ins a a_�__ aa; rr•__ i•__
1111 1Grlil is I�i uiG nla%,GCLGi tv LanG 8� uii�8 vt si�ial iiiapeGiion
PART 1: To be completed BEFORE PERMIT ISSUANCE
JOBSI E ADDRESS:
`i 19 `7` (5i , J arm i 5s cis ,
CO RACTOR NAME:
CONTRACTOR STATE LICENSE #:
�eP.-,J� +
PANEL WAKE :
PANEL MODEL #:
S0L ,4 JZ=??
T _ 0G1Q -P '1
PART 2: To be completed PRIOR TO INSPECTION REQUEST
and placed with jobsite inspection card
DECLARATION:
I, /—,'Owe(I (I declare that the PV module make and model
(PRLNT 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.
S 3 a3
(5 A ) V V IDATE)
3-]-I6