WORK PLANS - Laserfiche WebLink

Home Browse Search

APPROVED BY: California Department of Public Health OFFICE USE oN�Y Compliance Form Anti-Entrapment Devices and Systems DATE: for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE:Use one form for each pump or multiple pumps under the same drain cover, ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form Is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 and., 116064.2. Under Section 116064.2(a) of the Health and Safety Code,effective Janus 1 2010, the owner of a c swimminool shall file this form within 30 days following the completion of construction or Installation of anti entrapment devicles or systems In swimming pools, Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. j Site I f rmatio Facility Name: U A-AA 7-1,056,2 £ Pool Identification(if more than 1 pool/spa shite): k��_ Facility Address: City: l(}>�J St: �- ZIP: Owner Name: Owner's Phone Number: I Owners Address City St. ZIP ' Pool constructed on or after January 1,20101: 0 Yes 13 Recirculation Pump ❑ Jet/Booster Pump Make/Model H P Make/Model H P O Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H,P , Main VLainInclud 1 Suotlon SAIM& Manufacturer of approved drain cover. Model Number:A 10--pe Fit Instal , GPM rating:Floor 1 Wall Installed CHI r ❑ Wall l date 49 Manufacturer of approved drain cover: Model Number: GPM rating:Floor Wall Install date Check One: Installed on 13 Floor ❑Wall Main drain/Jet suction pipe size is inches. ,,P-Split main draln(s)(Minimum 3 ft,between covers,hydraulically balanced and symmetrically plumbed) MMff ❑ Single drain-Unbockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) ❑ Single drain-Not unblockable (one of the following secondary devices required: safety vacuum release system,auction limiting vent system,gravity drainage system,auto pump Shut-off system,or other equally or more effective system approved by enforcement agency) Type of secondary device installed: Install date Manufacturer of approved device: --�— Safety vacuum release system bears the followingModel/Part Number: performance standard markings:❑ ATSM F2387 O ASMI:/ANSI standard A 112,19.17 Skimmer Hguaffzer Linefsl Manufacturer of approved suction fitting: Mode!Number: Install date GPM rating:GPM rating:Floor Well Installed on ❑Floor ❑ Wall Skimmer equalizer line(s)pipe size were found to be ,Inches Number of Skimmers: '2— T is OViE A- SEEN FIE D VERIFIED TO CoMpLY MA I declare that I hold an active California State Contractor license#_ to ? ,S LLAT N E r-- IMMLLgR Professional Engineer license# �7—Z�with classification -J 3 or a Califomla State provided above is true to the best of my knowledge. I understand d that qualified experienceimpropedIy certify his public Informat oln9 shall be subject topools and that the potentialdisciplinary action at the discretion of the licensing authority In accordance with California Health&Safety Code Section 116064.2. Contractor/Engineer Name:Al iii E' !f�e l6©t_� e LL— C Company Name: t�1u't S J £,['/e� p S i Company Address: �, bst City: 15� I State: Zip Code: Contractor/Engineer Phone Number. Contractor/Engineer FAX Number. 'ZDD Cell Phone Number: �� —6,Z 11 1,11 11all: FK GI��L' t�u tK N&ketI Contractor/Engineer Hama(PRINT) CO ctor Engineer name IGNATU E) pa ca For a complete text of the law,visit: http:l/info-sen. -gov/pub/0 10/blli/asm/ab_1001-105 b 1020 bill Date Revised:July 14,2010 I