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G Development Group
7 ' . LLIf La
NEW SWIMMING POOL
PLAN SUBMITTAL AFFIDAVIT
Ordinance #2046
Please type or print •'' •
Date 2-Ee3 2.6 Zoo
Property Address S�7 J3 ti LiGi
Name of Property Owner s .7)(.A N ry
I- No children less than six years of age reside at this address.
II. El A child under the age of six years of age resides at this address.
(If this box is checked,Identify method of Secorndar'y 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.
(COMPLETE REVERSE SIDE)
I .
14 1 Community
G 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. , ❑ The above ground swimming pool shall have ladder secured.
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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.
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Name of Home Owner (Print) ome Owner Signature Date
Pool Contractor (Print) Contractor Signature Date
Si-.ETA TURI: OF OWNER TST B.E.NQTA RIZED-<.__ - .:
State of Arizona
County of Maricopa
On this c9(.0—day of 0(0 a i'cj , 20 Lam' , before me personally
appeared �nr-\ J0, m __ (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.
1 0 sr,. DIANA FIGUEROA I
(se* / rnry a1 Notary Public,State of Arizona
(0 (r�`' "��
Maricopa County
My Commission Expires Notary Pu 'c
°' °++ August 15,2011 I
re% Community
GLENDf_E Development Group
ADDENDUM TO BUILDING PERMIT NUMBER(S) (42q°0
5-P-16 L4'1 La _J
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 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 a
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 "unsworn falsification," a criminal
misdemeanor.
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Printed name of Applicant Si nfitu of Applicant Date
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