HomeMy WebLinkAboutXR2022-2530 - MiscCITY OF NEWPORT REACH
MMN11lNITV I)V%'FL0Pi/F NT DEPARTMENT
BUILDING DIN I%ION
itki %ivw Center Drier j P D nix 1 TfA I Nmvpml Beach, CA 926546915
wvwv a otav I {949) R44-3200
CONTRACTOR/PROPERTY OWNER SELF-CERTIFICAVON DECLARATION
FOR PLUMBING FIXTURE REPLACEMENT
Prulact Address 12 �y_� 1 , •�
Data /mod!_ Porno xt22�
The lottovAng is to be completed by the California licensed contractor or owner, participating in the City of Newport
Reach Sell-Codificabon Program, Please type or print
Installers Nuene 1r_,y"i�J�� I<G Licamsa Na I: apWcaWI�C!�
Amilattei's Maihnq Address/�p�v��1L1,Z�i�iiL�`� e s (required)" 109-041r'4404/
Installers Em,v s�1,�,�Z
IGiW(ot
i certify that the installation is in compliance with applicable code requirements
I furtturr affirm that t hm*reviewed and understand the reginraments of the 2019 Cal4nrnis Green Budging Standards
Code (('G8SC) Seclo n 301 1 1 and that all self -[emit anion reports submitted wig be based onlhe Code raqurnmanis
contained therein
I declare that all plumbing fixtures subject to the CGBSG 301 1 1 has basn replaced meeting the low flow
nequlre"ritt
Nitchan faucets 1 8 gaUminule at 60 psi Shower h•siis 1 8 gairminute at 80 psi
Water closet 1 28 galftlush - Faucets maximum fivrr rate of 1 2 gaUrrvrxrle at 60 pw
and mmirmim 0 9 91Wminure at 20 psi
,. t� r s 4�ertvr tore
Proatm 0nN11Rr fRoquirod)
As the property owner ql the prolort address noted above. I have read. undarslan0 and agree to participate in the
Plumbing Fixture Bepiacemant Self -Certification Program I further understand that by particApatuig in"onogrun. the
plumbing system will not be inspected by a City of Newport Beach Building inspector during construction or agar
installation nlosF reuested The Buildinq Division may request and resereas the nght to venty rode compliance after
the instal li i' lete�
This form must be completed and returned to the City of Newport Beach, Building Division, for a final approval
of the combination permit. Pines* return this fort to the Building Division by mail or fax.
Please mail tr City of Newport Teach Phone (949) 7t8.1888
Communfly Development f)onailment Fax a (9491644-3250
Building Division
P O 'Box 1768
Newport Beach CA 92658
ru�ma�4.YGxiEfe..�.a5a+i laetflayie.eWn-Y4-taeq r#era Had+"rn�e�e �SIY'::