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Community
GLENp Development Group
NEW SWIMMING POOL PLAN SUBMITTAL AFFIDAVIT
Ordinance#2046
Please type or print
Date vi( 3� 1,3
Property Address ? S(P 5 ink . Y-se. I An
Name of Property Owner l2-r ci cl t
�—
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 ss
required by the Glendale Pool Barrier Ordinance.
B. 0 We will provide exterior fence and enclosure protection with
secondary protection as checked on reverse side of this affidavit per th;
Glendale Pool Barrier Ordinance.
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IF YOU CHECKED BOX II B, PLEASE COMPLETE REVERSE SIDE
WHICH IS THE NEXT PAGE IN THIS DOCUMENT
THIS IS THE REVERSE SIDE OF THE PREVIOUS PAGE
1. 0 The pool shall be protected by a motorized safety pool cover.
2. ❑ Doors and windows are protected
3. ❑ The pool shall be protected by an alarm maintained in or on the
swimming pool.
4. 0 The above ground swimming pool shall have a secured ladder.
5. ❑ Locking hard safety cover on the spa or hot tub.
b_ 0 Alternative protection not specified above which is attached to the
plan submittal and submitted for approval by the Building Official
t4 v� Co(a d J_I r 30 vo r3
Name of Home Owner Home Owner Signature Date
Pool Contractor Contractor Signature Date
SIGNATURE OF OWNER MUST BE NOTARIZE
Stateof Arizona TRICIA C-ARIZ
NOTARY DU$UC-ARIZONA
MAAICOPA COUNTY
My Commission Expires
County of Maricopa o .�
November 30,2013
On this day I 20 ( before me, personally appeared
l I �1��y t() (name of signer),whose identity was
proven to me on the basis of factory evidence to be the person whose name is
r- . subscribed to in this document, and who acknowledged that he/she signed the
above/attached document.
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