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GLENE
NEW SWIMMING POOL
BARRIER AFFIDAVIT
Ordinance#2046
Please tvue or print:
Date ?— I -
Property Address (p 9 s C) c,,) 0 k)(,vj
Name of Property Owner VAC,-- �-.�-- �Pa Q (j\ C\C_O
I. No children less than six years of age reside at this address.
II. ❑ 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. ❑ We will provide an interior fence and enclosure around the pool as
required by the Glendale Pool Barrier Ordinance.
B. ❑ 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)
City of Glendale
Development Services•5850 West Glendale Avenue•Glendale,Arizona 85301-2599•Phone(623)930-2800
www.glendaleaz.com
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❑ 1. The pool shall be protected by a motorized safety pool cover.
O 2. Doors and windows protected.
O 3. The pool shall be protected by an alarm maintained in or on the
swimming pool.
❑ 4. The above ground swimming pool shall have a ladder secured.
O 5. Locking hard safety cover on the spa or hot tub.
O 6. Alternative protection not specified above which is attached to the
plan submittal and submitted for approval y the building official.
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Name of Home Owner(Print) Home Owner Si a Date
Pool Contractor(Print) Contractor ignature Date
SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona
County of Maricopa
On this I day of �--e j , 20.20 before me personally
appeared ��}- V,=c) 0 (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 signed the above/attached document.
�+ ►,.- JOHN BUTCHER
NOTARY PUBLIC-ARIZONA
Maricopa County
( +i Commission#568540
*:; � June 8.223
(Seal) Notary Public
City of Glendale
Development Services•5850 West Glendale Avenue•Glendale,Arizona 85301-2599•Phone(623)930-2800
www.glendaleaz.com