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!LPN Community
of
GLENDfLE Development Group
NEW SWIMMING POOL PLAN SUBMITTAL AFFIDAVIT
Ordinance #2046
Please type or print
Date J I l S, Z.011
Property Address &5'v W . Co /+e r 6 _ 6 I erk le, 14 2 $ 5 395
Name of Property Owner J O Se ,4 L.G4;e-; o Ni e z
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 the Glendale Pool Barrier Ordinance. .
B.y.44.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.
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1i19 7,Z�
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. ❑ The pool shall be protected by a motorized safety pool cover.
2. 71.. Doors and windows are protected
3. ❑ The pool shall be protected by an alarm maintained in or on the
swimming pool.
4. El The above ground swimming pool shall have a secured ladder.
5. El 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
Name of Home Owner Home Owner Signature Date
AZ 7/IS/l w
Pool Contractor Contractor Signature Date
SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona
County of Maricopa
On this t 9 day of A,/ , 20t9 , before me, personally appeared
2 - c/ `= y • (name of signer), whose identity was
proven to me on the basis of satisfactory ev'•ence to be the person whose name is
subscribed to in this document, and who : knowledged th. e/she signed the
above/attached document. A �z /C' -- �✓'
su.i. 14
, �' NGOTAARY PUBLIC-fiARTE n
MARICOPA COUNTY
Or al, My Conan Expires 04/10/2020
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