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1T CITY OF NEWPORT BEACH
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COMMUNITY DEVELOPMENT DEPARTMENT
u > t BUILDING DIVISION
cq FoaN P 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 926588915
www.newportbeachca.gov 1 (949) 644-3200
CONTRACTOR/PROPERTY OWNER SELF -CERTIFICATION DECLARATION
FOR PLUMBING FIXTURE REPLACEMENT
Project Address: /G /Z- (AfaA;Lr aal t A) - *ADR.
Date: o2- 9J-3 —202y Permit #: XT,t L 23
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: _�,�a A- License No (if applicable)
Installer's Mailing Address: Phone # (required):
Installer's
FAX
Installer
I certify that the installation is in compliance with applicable code requirements.
I 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
Installer's Signature
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
Print Name
Date
// !.L A�p :ate
a.
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-CertDeclamtion-Plumbing Fixture Replacement 03/04/22