HomeMy WebLinkAboutP2014-0173 - Misc (2)"P2o I Li - ci rI
-'(°I SL,}-e o
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDrNO DrVISZON
3300 Newport Boulevard I P.O. Box 1768 I Newport Beach, CA 92658
www.newportbeachca.gov 1 (949) 644-3275
[Voluntary]
CONTI R Ai TI O€11PROPERTY OWNER SELF-CERTI=TCA i 10"; DEC!AR ATInKi
FOR RESIDENTIAL PROPERTIES
(Water Heater)
ProjectA.ddress:'y9 J0.rAf0-r',0 Dv -
Date: 3
Permit #:
The following is to be completed by the California licensed plumbing contractor participating in the City of Newport
Beach Self -Certification Program when installing a water heater. Please type or print.
Contractor's Name: E v c rA5 P kLvrya i rc License No. I�T 0000 i qyl
Contractor's Mailing Address: Vlao lvh"iFier V+ Co0zji f AzcG Phone # (required):r-Iq9 - U4U - 11 `65
Contractor's Email:EvcLn ol.mhlr,l�Co1 (ovn FAX#: 549 LaCIke- 1501
Installer
I certify that the installation is in compliance with applicable code requirements. I hereby affirm under penalty of perjury
and under the laws of the State of California that I am licensed to perform plumbing work under provisions of Division 8,
Title 16, Article 13 of the Business and Professions Code, and my Class C-36 license is in full force and effect.
I further affirm that I have reviewed and understand the requirements of the applicable 2010 California Plumbing Code
and Newport Beach Municipal Code and that the self -certification report submitted by me will be based on the code
requirements.
This certification is for a WATER HEATER that is installed in the same location and is the same size and type. Seismic
strapping and TPR lin installed per 2010 California Plumbing Code.
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
System 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
complete.
Property owner's Signature Date
e Ya: Co , J'l - -
tint Name Email -
This form must be completed and returned to the City of Newport Beach Building Division for a final approval cf
the plumbing permit. Please return this form to the City Building Division by mail, fax, or send electronically.
Please mail to: City of Newport Beach
Community Development Department
Building Division
3300 Newport Blvd.
Newport Beach, CA 92663
Email: i x lc %reff _gr ez c ca,gpv
Fax #: 949-644-3250
Forms\contractor-cwner self- can ded atar neater 06/22/11