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CITY OF ; .WPORT BEACH
COMMUNITY DE ELOPMENT DEPARTMENT
BUIL )ING DIVISION
100 Civic Center Drive I P.O. E ox 1768 1 Newport Beach, CA 92658-8915
www.newportbe ichca.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:
V,C, LC)o NO
CONTRACTOR NAME:
CONTRACTOR STATE LICENSE #:
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10 3 ICI O
PANEL MAKE #:
PANEL MODEL #:
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PART 2: To be completed PRIOR TO INSPECTION REQUEST
and placed with jobsite inspection card
DECLARATION:
I, Gl� r ' 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
referenced_04�'ss'Within the City of Newport Beach.
(DATE)