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G Development Group
NEW SWIMMING POOL
PLAN SUBMITTAL AFFIDAVIT
Ordinance#2046
Please type or print
Date — OS
Property Address ( 30 kS dC> Lai) e
Name of Property Owner ,\ �V �� `1 a
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 as 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 the Glendale Pool Barrier Ordinance.
(COMPLETE REVERSE SIDE)
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dj Community
G Development Group
1. ❑ The pool shall be protected by a motorized safety pool cover.
2. ❑ Doors and windows protected.
3. 0 The pool shall be protected by an alarm maintained in or on the
• swimming pool.
4. ❑ The above ground swimming pool shall have ladder secured.
5. ❑ Locking hard safety cover on the spa or hot tub.
6. 0 Alternative protection not specified above which is attached to the
&erliy
plan submittal and submitted for approval by the building official.
�Z5bbS Q4 -15- v5Name Home Owner (Print) Home O r '� a Signature Date
Vertu . b k a- (s-o.-
Pool COntractor (Print) Contract Signature Date
SIGNATURE OF OWNFR MUST RE NOTARIZED . .
State of Arizona
County of Maricopa
On this , di of , 20 0 before me personally
appeared �- S (name of signer), whose
identity was proved t 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.
(seal) ,:� ' t� tclat sent.
"�:�:='� KOPIANN MORALES
NOTARY PUBLIC-State of Arizona Notary Public
`' MARICOPA COUNTY
My Comm.Expires July 19,2008
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ADDENDUM TO BUILDING PERMIT NUMBER(S)
(2,30 0 , l orkic , , Lane 61e0 , 4 2 25 /0
The undersigned applicant asserts that she or he is exempt from the contractor licensing requirement
of Arizona Revised Statutes Chapter 10, Title 32 on the basis of:
JARS 32 1121.A.5. The applicant owns the property and shall property, o
pp p p y occupy the 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 cloy
licensed contractor(s) al! 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
AP,S 32-1121 .A.7. The applicant is a registered architect or enc veer, or employee o a
registered architect or engineer engaged in professional practice, nc: as a contractor.
he un:ersigned swears a nc affirms that the information herein is :"ue and accurate, any
acr:no!..!e 'ges that the filing of an application containing false or in ` on with the inter!:
correct �;,rma:.�
to avoid the licensing or tax requirements of the State of Arizona is "unsv.c-., falsification," a cri;n':na
misdemeanor.
"3evoriq bps -ns
Printed name of pplicant Signature of AI• cant Date
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Community
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Deve1oment Group
ADDENDUM TO BUILDING PERMIT NUMBER(S)
6308 60. Pc,r- f S-3 / O
The undersigned applicant asserts that she or he is exempt from the contractor licensing requirement
of Arizona Revised Statutes 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 appfican,t, and/or performed by
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 ha•.'e the work performed on;
by duly licensed contractor(s) all of whom are identified below -or on the attached.
Contractor/Company Name License Number Classification
•
A=:S 32-1121.A.7. The applicant is a registered architect or en.� neer, or employee c•: a:
registered architect or engineer engaged in professional practice, nc: as a contractor.
The u„-.ersigned swears an: affirms that the information herein is :-ue and accurate a :.
aCir;no'.. i !ges that the f:. ng c' it apt ,c2tion containing i?!se or Incorrect -..formatori with the ln.
to avoi;, the licensing or tax r: irenie ,ts of t'ne Sate f / iz s'•'•: ., 's t Crin-
.G� or ,-.-� ona is un �a �a ion, a
msder-:eanor.
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Printed rame of Applicant Signature of Applicant Date
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