HomeMy WebLinkAboutP2024-0115 - Miscate. CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
C"=rt z BUILDING DIVISION
z 100 Civic Center Drive I P.O. Box 1768 j Newport Beach, CA 926588915
www.newportbeachca.gov j (949) 644-3200
[Voluntary]
CONTRACTORIPROPERTY OWNER SELF -CERTIFICATION DECLARATION
FOR RESIDENTIAL PROPERTIES
(Water Heater)
Project Address: t t/ % l/4 ld//17t' Df`7�C , � t' �t ^` ����%h , «
Date: 3^ lam^ A2 _L Permit#: )0202#-0/157
The following is to be completed by the California licensed plumbing contractor participating in the City of Newport
Beach Self -Certification Program when installing a water heater. Please type or print. Q
M..7h"%`ar-, r y8�(%8
Contractor's Name: / nC� License No -
—
Contractor's � l✓e. Phone # (required
): /
Contractor's Mailing Address s 1./
Contractor's Email: ��' t, / 9.1_865' FAX #: ^
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Installer
I certify that the installation is in compliance with applicable code requirements. I hereby affirm under penalty of perjury
and under the laws of the State of California that 1 am licensed to perform plumbing work under provisions of Title 16
Article 13 of the Business and Professions Code, and my Class C-36 license is in full force and effect.
I further affirm that I have reviewed and understand the requirements of the applicable 2019 California Plumbing Code
and Newport Beach Municipal Code and that the self -certification report submitted by me will be based on the code
requirements.
This certification is for a WATER HEATER that is installed in the same location and is the same size and type. Seism!_-
strapping anq_TPR tyre installed per 201 �lifomia Plumbing Code.
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 unlw<,
requested. The Building Division may request and reserves the right to verify code compliance after the installation is
complete.
Property
3-/s-
Date
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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: (949) 718-1888
Community Development Department Fax #: (949) 644-3250
Building Division
P. O Box 1768
Newport Beach, CA 92658
rnrme\Contractor-Owner-Sett-Cert Declaration-Wale,Heater 0:29/20