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Gl Development Group
OWNERBUILDER ADDENDUM TO BUILDING PERMIT NUMBER(S) / 3) 6 35
ADDRESS 1 al aaa /U.. 4/4 k L N ( (1€ 1AL) k ► 242 A- S'3dal
-The undersigned applicant asserts that she or he is exempt from the original contractor licensing requirement
of Arizona Revised Statues Chapter 10, Title 32 on the basis of:
XARS 32-1121.A.5. The applicant owns the property and shall occupy the property, and does not intend
the property to be for sale or rent, and shall have the work performed by the applicant alone, or by the
applicant with employees of the applicant, and/or performed by duly licensed contractor(s) all of whom
are identified below or on the attached.
— ARS 32-1121.A.6. The applicant owns the property and shall have the work performed only by duly
licensed contractor(s) all of whom are identified below or on the attached.
Contractor/Company Name License Number Classification
ARS 32-1121.A.7. The applicant is a registered architect or engineer, or employee of registered
architect or engineer engaged in professional practice, not as a contractor.
The undersigned swears and affirms that the information herein is true and accurate, and acknowledges that
the filing of an application containing false or incorrect information with the intent to avoid the licensing or
tax requirements of the State of Arizona is "unsworn falsification," a criminal misdemeanor.
,V IC 05 13-- -
Printed Name of Owner Signature of Owner Date
City of Glendale * 5850 West Glendale Avenue.*Glendale, Arizona 85301-2599 * (602)930-2800
City of Glendale
GLEMIE Development Service Center
SWIMMING POOL
BARRIER AFFIDAVIT
Ordinance#2046
Please type or print:
Date K,1 - 14
Property Address -) L /� / G i end„ 1 !=a /4 2 c r?o
Name of Property Owner Al 0-E S vn; C
I. g No children less than six years of age reside at this address.
II. 1 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)
Page I of 2
riP
IPA", City ofGlendale
Gli-ENDfEDevelopment Service Center
❑ 1. j he pool shall be protected by a motorized safety pool cover.
❑ 2. Doors and windows protected.
❑ 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.
❑ 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 submitted for approval by the building official.
Ai)(.;elo 5 _ 1
Name of Home Owner(Print) Home Owner Signature Date
Pool Contractor (Print) Contractor Signature Date
SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona
County of Maricopa
On this day of da-n(1(,,r6( , 20/'� , before me personally
appeared 11� v 5 /yt)i1 i _ (name of signer), whose
identity was pried 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.
DIANA FIGUER e A
c Notary Public.State of Arizona
MARICOPACOUNTY
My Commission Expires
August 15,2015 RA
(Seal) ary Public
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