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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
SOLAR CONTRACTOR DECLARATION
Keep 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:
CONTRACTOR NAME:
r-RotA'I'A-
CONTRACTOR STATE LICENSE #:
AN L M E #:
PANEL MODEL #:
U1,1 2n t� Duo
A& 3 zo Ll/
PART 2: To be completed PRIOR TO INSPECTION REQUEST
and placed with jobsite inspection` card
DECLARATION:
I, s 1t7S�n r declare that the PV module make and model
(PPN-T 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.
(SIG ATU E) (DATE)