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CITY OF NEWPORT BEACH
c� f' "k COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
FC)Rwww.newportbeachca.gov 1 (949) 644-3200
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I Li www.newportbeachca.gov
CONTRACTOR DECLARATION
Keep with Inspection card.
This form is for the Inspector to take at time of final inspection
PART n1-, To ho eoro piete(l BFFORE PERM18T ISSIJANCE
JOBSITE ADDRESS:
jI L'," 1-/-1
CONTRACTOR NAME:
CONTRACTOR STATE LICENSE #:
'
PANEL MAKE #:
PANEL MODEL #:
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'T t4o 0 !� 71
DECLARATION:
I t (PRINT NAMEE)) declare that the PV module make and model
`'
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.
(SIGNATU(DATE) //