HomeMy WebLinkAboutX2021-2944 - Misc (3)CITY OF NEWPORT BEACH
e� COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
O 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachca.gov 1 (949) 644-3200
�V,N,V ,
[Voluntary]
CONTRACTOR/PROPERTY OWNER SELF -CERTIFICATION DECLARATION
FOR RESIDENTIAL_ PROPERTIES
(Dishwasher, Garbage Disposal, Dater Closet)
Project
Date:
The following is to be completed by the California licensed plumbing contractor or owner -builder, participating in
the City of Newport Dpeph Self -,Certification Program. Please type or print.
Installer's Name:_�,p
Installer's Mailing Ad
Installer's Email: O"
�Liic�-ense No (if applicable) � 5?1� _/1V
Phone # (required): �z��%•
FAX #:
Installer a
I certify that the installation is in compliance with applicable code requirements.
I further affirm that I have reviewed and understand the requirements of the applicable 2013 California Plumbing Code
and Newport Beach Municipal Code and that all self -certification reports submitted will be based on the rode
requirements contained therein.
Please check the appropriate box below for work to be completed under this Self -Certification declaration:
DISHWASHER. Installed same size and in the same location. Air gap fitting installed per
2013 California Plumbing Code, 807.4.
GARBAGE DISPOSAL. Installed same size and in the same location.
WATER CLOSET. Replaced in the same size and 1.28 gallon per flush.
lnst 1 is Si nature Date
Property Owner (Required)
As the property owner of the project address noted above, I have read, understand and agree to participate in the
System Self -Certification Program. I further understand that by participating in this program, the plumbing system will
not be inspected by a City of Newport Beach Building Inspector during construction or after installation unless
requested. The Building Division may request and reserves the right to verify code compliance after the installation is
complete. _
Property Owner's Signature - +�_Date
Print Name Email
This form must be completed and returned to the City of Newport Beach, Building Division, for a final approval
of the plumbing permit. Please return this form to the Building Division by mail or fax.
Please mail to: City of Newport Beach Phone: (94-9) 718-1888
Community Development Department Fax #: (949) 644-325Q
Building Division
P. O. Box 1768
Newport Beach, CA 92.658
Forms\Contractor-OwnerSelf-CertDeclaratiori-DishwasherGarbageDispWaterCloset 08/11/16