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Development Group
OWNER/BUILDER ADDENDUM TO BUILDING PERMIT NUMBER(S) 7 (c)Si
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ADDRESS LpS� �� , ': J RC JT
- The undersigned applicant asserts that she or he is exempt from the original contractor licensing requirement
of ArizonaRevised Statues Chapter 10, Title 32 on the basis of:
A
" ARS 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
S .T3NA V)'R QARIA s(zS\ f(a)A, e)\
- 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 "uns \ lsi ion," a criminal misdemeanor.
WA\td Va,11 113
Printed Name of Owner :nature Owner Date
City of Glendale * 5850 West Glendale Avenue.*Glendale, Arizona 85301-2599 * (602)930-2800
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City of Glendale
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GLIO\ILIEDevelopment Service Center
_ _. SWIMMING POOL
BARRIER AFFIDAVIT
Ordinance#2046
Please type or print:
Date ,5'i `?, L3
Property Address () 5 � �
; � 1 (-A Se
- 1 C- (—Eh)DP'€ 02-
Name of Property Owner c. ) t L D Ai_ . C�
I. No children less than six years of age reside at this address.
II. i 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 1 of 2
City of Glendale
Gr-, Development Service Center
❑ 1. The pool shall be protected by a motorized safety pool cover.
❑ 2. Doors end 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.
1-Amt--3 \RuSe9. 1-1)CeiCe
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 ,(0 day oft , 20 t 3 before me personally
appeared Qc u aLo ci Ze- (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.
N.�iery muutrStaute aariiona
IuiARICORACOIiNTY
• Wly Commission Exphea
MOW 15,2015 utaiLa
ea ) Nota ublic
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