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Cityof Glendale
Mb
}LDevelopment Service Center
_ SWIMMING POOL
BARRIER AFFIDAVIT
Ordinance#2046
Please type or print:
Date 6-J i i.,1 14
cic, - -4(01'h \DF—
Property Address (( \ r
Name of Property Owner ��\cFn- • N1 Di K �16 (Z'
I. 4„ No children Iess than six years of age reside at this address.
id. Lii of age, resides at this address.
A child under the age six ycai s of u��
(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 GleripDal Ban-ierOr.i. . ■c-. '
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(Complete Reverse Side)
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%aril City ofGlendale
Gi-ENntE Development Service Center
O 1. The pool shall be protected by a motorized safety pool cover.
* (N2. Doors and windows protected.
❑ 3. The pool shall be protected by an alarm maintained in or on the
swimming pool..
❑ 4. The above ground swimming pool shall have a ladder secured.
❑ 5. Locking hard safety cover on the spa or hot tub.
1 6. Alternative protection not specified above which is attached to the
plan submittal and submitted for approval by the building official.
/1/G/xo /t//�rry 8-6 z
Name of Home Owner(Print) Home Owner Signa Date
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Pool Contractor Print '� Contractor Signature Date
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SIGNATURE OF OWNER MUST BE NOTARIZED
State of Arizona
County of Maricopa
On this 7 day of 1 ay , 20 1 '), before me personally
appeared G -4name of signer), whose
identity was proved o me on the basis of satisfactory evidence to be the person
whose name is subscribed to in this document, and who acknowledged that
i ned the above/attached document.
"R'' , Dubuc - ial ' , T RYN MAGGI
�' A �' Nor• Public-Arizona
oP1 County ..y� t , rpa County
3.0 MY ris sic 1 Ex. �. �, n y Corr fission ExpMN
5.2016 s's n l May 15, 2015
(Seal) . ary Pub is
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