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NEW SWIMMING POOL PLAN SUBMITTAL AFFIDAVIT
Ordinance#2046
Please type or print
Date rJ
Property Address /O 17 /v? .oft v '�-
Name of Property Owner'1-7-0G+M 5 e; G Y
I. Or- 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.
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IF YOU CHECKED BOX II B,PLEASE COMPLETE REVERSE SIDE
WHICH IS THE NEXT PAGE IN THIS DOCITMENT
TI3(IS IS THE REVERSE SIDE OF THE PREVIOUS PAGE.
1. 0 The pool shall be protected by a motorized safety pool cover _
—2. -C]—Doors and window"s`are protected
3. 0 The pool shall be protected by an alarm maintained in or on the
swimming pool.
4. 0 The above ground swimming
5. 0 Locking hard safety cover on the spa or hot tub.secured ladder.
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
Pool Contractor Contractor Signature
Date
SIGNATURE OF:OWNER_WIUS-T-BE OTARIZED -
State of Arizona
County of Maricopa
On this_ _day of 20 \LI , before me,personally appeared
-�-6,�1� 0. pp
(Y)c jIna? (name of signer),whose identity was
proven to me on the basis o€e atisfactory evidence to be the person whose name is
subscribed to in this document, and who acknowledged that he/she signed the
above/attached document.
N A2 Cattngrof maricl.ro,
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(Date) j 7n�tR., uhAC
County,AtIz0lt8
My Comm.sores 1013-17
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