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City of Glendale
GLED49-17 Development Service Center
SWIMMINGBARRERAFFPOOL
Ioz"TIT
Ordinance#2 046
Please type or print:
Date 1°12-11
A
Property Address 041 it4 Ot ANti elit..4..dt )4 1- OF26°-
Name of Property Owner kfl..t,t1ti it s
I. k No children less than six years of age reside at this address.
H. 0 A child under the age of six years of age resides at this address.
(If this box is checked, identify method of secondary pool protection.)
A. Li We will provide an interior fence and enclosure around the pool as
required by the Glendale Pool Barrier Ordinance.
B. D We will provide exterior fence and enclosure protection with
secondary protection as checked on reverse side of this affidavit
per the Glendale Pool Barrier Ordinance.
(Complete Reverse Side)
)
1
City of Glendale
{- - Devekrment Service Center
1.. The pool shall be protected by a motorized safety pool cover.
Doors and windows protected.
Li 3. The pool shall be protected by an alarm maintained in or on the
swimming pool.
1 4. The above ground swimming pool shall have a ladder secured.
L 5. Locking hard safety cover on the spa or hot tub.
6. Alternative protection not specified above which is attached to the
plan submittal and submit d for approval bye building official.
Name of Home Owner(Print) orne Own&T ignature Date
4LS11t __ ,43 RvC?91tt -1r1t., /0 /7
Pool Contractor(Print) Contract Si ature at
SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona
County of Maricopa
On this d ; OG.�.I
�/ of l U beY"" 20)5, before me personally
appeared �1±?.. .._�...1?5d�'� (name of signer), whose
identity was proved to me on the basis of satisfactory evidence to be the person
whose name is subscribed to in this document, and who acknowledged that
he/she sinned the above/attached document.
i. SHANNON PUTROW
. NOTA?Y PUBLIC-S'ATE Of ARiZONA
f MARICOPA CCUNTY
• :,' MY COMM`:SSION WIPES
• ,.,. MARCH 6.2017
(Seal) — Notary Public
PaCe.2of2