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CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
' n BUILDING DIVISION
U S. 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
Cq</FORN�P 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:
45 2�ia
CONTRACTOR NAME:
CONTRACTOR STATE LICENSE #:
PANEL MAKE #:
PANEL MODEL #:
JA
JAA15q&3L -3
PART 2: To be completed PRIOR TO INSPECTION REQUEST
and placed with jobsite inspection card
I, %VI 6gphiih declare that the PV module make and model
(PRINT 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
address wit.Wn'fhe)Eity of Newport Beach.
317 /Z3
(DATE)