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F 3 m �om mm. a'(7 wpm �ma' � J n. m ti O! p ( f3 mj am as Iry D m.w n n D Qcmi,', mo <a mom a. a ym a O mi n mam m p c m � g o Wmi m FOm O'"m �i 0 = w N 3prj m Q O O.m m a m m n. o c m�i m c 3:•p m5ii 3 p O Y K N CITY OF NEWPORT BEACH COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 926588915 www.newportbeachca.gov 1 (949) 644-3200 x 22o 2-3 - 07 0 0 -I R.UC \J 1 a15 CONTRACTORIPROPERTY OWNER SELF -CERTIFICATION DECLARATION FOR PLUMBING FIXTURE REPLACEMENT Project Address: 7 %ie V i l/oo Date: ?,—/Z I z ' Permit #: X R .=IQ , -OW The following is to be completed by the California licensed contractor or owner, participating in the City of Newport Beach Self -Certification Program. Please type or print. Installer's Name: v tekkrftbltil) License No (if applicable) / /iSGQ�!i Installer's Mailing Address: Phone* (required):5Pq9 :5"a 2 � K Installer's Email: Y42arlw . j n t te. c 0 M FAX #: Installer certify that the installation is in compliance with applicable code requirements. further affirm that I have reviewed and understand the requirements of the 2019 California Green Building Standards Code (CGBSC) Section 301.1.1 and that all self -certification reports submitted will be based on the code requirements contained therein. I declare that all plumbing fixtures subject to the CGBSC 301.1.1 has been replaced meeting the low flow requirements: Kitchen faucets: 1.8 gal/minute at 60 psi Shower heads: 1.8 gal/minute at 80 psi Water closet: 1.28 gal/flush Faucets: maximum flow rate of 1.2 gal/minute at 60 psi, and minimum 0.8 gal/minute at 20 psi j�i - 9f2r %2a Installer'kSignature Date Property Owner (Required) As the property owner of the project address noted above, I have read, understand and agree to participate in the Plumbing Fixture Replacement 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 L� 9j2%23 Property Owne Srgna Date Print Name This form must be completed and returned to the City of Newport Beach, Building Division, for a final approval of the combination 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-OwnerSelf-CertDeclaration-Plumbing Fixture Replacement 03/04/22