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�� Development Service Center
NEW SWIMMING POOL
BARRIER AFFIDAVIT
Ordinance#2046
Please type or print:
Date \_:) — ,f —/ 27/
Property Address of(?)9 )"(') ( 2') / 1ye
Name of Property Owner r
I. / No children less than six years of age reside at this address.
II. n 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. 1 We will provide an interior fence and enclosure around the pool as
required by the Glendale Pool Barrier Ordinance.
B. Li 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 Rev i 4' r
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City of Glendale
GLENFIE Development Service Center
❑ 1 . The pool shall be protected by a motorized safety pool cover.
it 2. Doors and windows protected.
❑ 3. The pool shall be protected by an alai in maintained in or on the
swimming pool.
1 4. The above ground swimming pool shall have a ladder secured.
1 5. Locking hard safety cover on the spa or hot tub.
C 6. Alternative protection not specified above which is attached to the
plan submittal and submitted for approval by the building official.
c_j OA
Name-of Home Owner(Print) om - wner Signa re Date
Pool Contractor (Print) Contractor Signature Date
SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona
County of Maricopa
On this 3 day of MCLAI , 20) q, before me personally
appeared G u `� _ (name of signer), whose
identity was proved 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.
BARBARA JEAN DURBIN
NdaymAmPutrogtegnykizons ietizajtiL-
*Commisso4 Wee Dee.U,20fs Notai Public
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