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GLENDfE Development Group
NEW SWIMMING POOL PLAN SUBMITTAL AFFIDAVIT
Ordinance #2046
Please type or print
Date - 0—t q
Property Address I! 5 t 6? 4 4 0 5 rig f)(240
Name of Property Owner [,pt L5 Ir UfhV Dez
I. V 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 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.
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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. ❑ 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. El The above ground swimming pool shall have a secured ladder.
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
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Name of Home Owner Home Owner Sign e Date
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SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona
County of Maricopa
On this day of J (.( /y , 20 (" , before me, personally appeared
C 0 LI J -0nOhd/Z (name of signer), whose identity was
proven 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 e si ed the
above/attached document.
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.we sL; VANESSA SALCIDO I
1114
z 4 Notary Public-Arizona
Maricopa County
Commission r 549848
My Comm.Expires Jul 22,2022
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OWNER/BUILDER ADDENDUM
OWNER/BUILDER ADDENDUM TO BUILDING PERMIT NUMBER(S)
ADDRESS illt U l,SP1 OP va't a( ✓V 0,4-LP C's 3a5
The undersigned applicant asserts that she or he is exempt from the original contractor licensing requirement of
Arizona Revised Statues Chapter 10, Title 32 on the basis of:
— 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
— 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 "unworn falsification,"a criminal misdemeanor.
s
Printed Name of Owner Signature wner Date
City of Glendale
Development Services•5850 West Glendale Avenue •Glendale,Arizona 85301-2599• Phone(623)930-2800
www.glendaleaz.com