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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
CONTRACTORIPROPERTY OWNER SELF -CERTIFICATION DECLARATION
FOR PLUMBING FIXTURE REPLACEMENT
Project Address:
Date: O Z / a t l `Zn) 23 Permit #: �X 2CN 2 "'j - /09 L%
The following is to be completed by the California licensed contractor or owner, participating in the City of Newport
Beach Self-CertificationProgram. Please typec
or print. �7
Installer's Name: C n11 Dt,�e'�S kX%,v C8 Ova 21f License No (if applicable)9 0 (1 3 h
Installer's Mailing Addre�ss: L &,ti L--1,5�:,�t� enf , Phone # (required):�S�L
Installer's Email C ctk1% N%, v Kok V\-erc FAX #:
Installer @Sv\� \ • Ccfl W,_
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 12 gal/minute at 60 psi,
and minimum 0.8 gal/minute at 20 psi
CD 20 23
T 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 regtje The Building Division may request and reserves the right to verify code compliance after
the
Signature I�— Date
Print Rame Email
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
FormslContractor-OwnerSelFCertDeclaration-Plumbing Fixture Replacement 03/04/22