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Community
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Development Group
NEW SWIMMING POOL
PLAN SUBMITTAL AFFIDAVIT
Ordinance#2046
Please type or print
Date 1 //3
Property Address h 5 8 7 LA ' 11 Q'‘) C(eiiia6 /� 2 0 `cg°q
Name of Property Owner Ere r1
I. No children less than six years of age reside at this address.
II. 0 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 provide an interior fence and enclosure
around the pool as required by 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 the Glendale Pool
Barrier Ordinance.
(COMPLETE REVERS SIDE)eeow TOO t
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Community
GLENL- E
Development Group .
1. ❑ The pool shall be protected by a motorized safety pool cover.
2. 0 Doors and windows protected.
3. 0 The pool shall be protected by an alarm maintained in or on
the swimming pool.
4. 0 The above ground swimming pool shall have ladder secured.
5. 0 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.
•
/R S red k, 0 Gae. _ h
ame of Home Owner(Pr' t) ome Owners Signa Date
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Pool Contractor(Print) Contractor Signa ure Date
SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona
County of Maricopa
Othis 111A day of Ytt, ,,20 before me personally appeared
t v- Ws.1c Con-1 (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.
`Viar% KENT NODP �^ :
(seal) 1 _�, Notary Puelic•Arizona Notary Public
♦ 'j 'd;` a., Muicopa county
• • My Comm.Expires Feb 10,2017
age 2 of 2