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NEW SWIMMING POOL PLAN SUBMITTAL AFFIDAVIT
Ordinance #2046
Please type or print
Date 7//V) `�
Property Address/ gazq /-✓. 0 Sl77 /l'yG ( 4_,,,m / ,22 6'5
Name a-Property-Own cS&
I. X 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. 0 We will provid Ma> terior fence andridlosure around the pool as
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required by the Gl dale Pool Barlier Orci .a.nce.
B. 0 We will provid e.N.tQrior fuzi ,ea.andicldsure protection with
secondary protection as checked on reverse side of this affidavit per the
Glendale Pool Barrier Ordinance.
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IF YOU CHECKED BOX H B, PLEASE COMPLETE REVERSE SIDE
WHICH IS THE NEXT PAGE IN THIS DOCUMENT
THIS IS THE REVERSE SIDE OF THE PREVIOUS PAGE
1. ❑ 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. ❑ The above ground swimming pool shall have a secured ladder.
5. 0 Locking hard safety cover on the spa or hot tub.
6. 0 Alternative protection not specified above which is attached to the
plan submittal and submitted for approval by the Building Official
C-Q.A-t c1 s • Sc 4AM ZI 7
Name of Home Owner Home r Signature Date
6A204( /12.0/_ 7/1sM
Pool Contractor Contractor Signature Date
SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona ,',, arta,
County of Maricopaa.,s sin
On thisC7 day of C\�t,6"� . 20 / , before me, personally appeared
CP_Oiqs 'V
5 SCCei O2 2 ( (name of signer), whose identity was
prove 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.
2012