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CITY OF NEWPORT BEACH
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COMMUNITY DEVELOPMENT DEPARTMENT COMMUNITY y
BUILDING DIVISION DEVELOPMENT
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 926588915
www.newportbeachca.gov 1 (949) 644-3200
SEP 2 4 9019
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CONTRACTOR/PROPERTY OWNER SELF -CERTIFICATION DECLARWgQ N qc`
FOR RESIDENTIAL PROPERTIES �C,FIT r
(Water Heater)
Project Address: (J — G qt-(
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Date: 17 r Z / - l 6_7 Permit
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. G
Contractor's Name: �Gt Ay//, IJ /Ot U �� t -01Un-rL (License No. l o z / 13a?
Contractor's Mailing Address:r/y7 '7 OYaou! n✓nST /o�//� Q Phone # (required)7
Contractor's Email: r pu,y r`� f/Q�(/ CA 9 2Y6$ FAX #:
Installer and I'Ctvud, Co",
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 I am licensed to perform plumbing work under provisions of Division 8,
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 2013 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. Seismic
strapping and TPR liny_ynstalled per 2013 California Plumbing Code.
Date
Property Owner (Required)
As the property owner of the project address noted above, I have road, 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.
roperty Owner's Signature Date
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Print ame 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
Forms\Contractor-Owner-Self-Cert Declaration-WaterHeater 08/18/16