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kektitractor 0 Owner CI Authorized Agent Date: I err the Signet Please-Win Name: Date Installed iL t 7 ‘40- PcI., .7krtr2., L-P " rt-frvf, 1- vet( (4-6 Manufacturer Model Mar 03 09 08:29a T 02/26/2009 13:36 21394648. 2097 -8877 ENVIRONMENTAL 11L7 P.2 YPIat or/ - t o< Declaration Property Address: \--ACD\ Property Owner's Name (Please Print): Property Owner's Phone #:T -3-2._‘---‘,-.7-R27.1 Mark all that apply to your property: This property does not have a swimming pool, toddler/wader pool, or spa. This roperty does have a (check all that apply): imming Pool 0 Toddler/Wader Pool 0 Spa T e permit requested does not include any work to be performed to the swimming pool, toddler/wader pool, or spa. The permit requested does include work to be performed to the swimming pool, toddler/wader pool, or spa. Installation Certification The following certification is required whenever a building permit is issued for the remodel or modification of a property's swimming pool, toddler/wader pool, and/or spa. Building Permit(s)#: Contractor's Name (Please Print):(Cti,•-• s., x---)1Phone #: Contractor's Company: Contractor's License NumberrnCrAl.-- Inspection Date(s): Building inspector's Name (Please Print): Classification:C erg r-, Anti-Entrapment Devices Installed: Description Drain Cover Safety Vacuum Release System (SVRS) Suction Limiting Vent System (SLVS) Gravity Drainage System Automatic Pump Shut-off System Drain Disablement Unblockable Drain Other: I hereby certify that the existing swimming pool, toddler/wader pool, or spa located at the above- mentioned address complies with the provisions of the *Swimming Peal Safety Act of 2006" and has been equipped with an approved anti-entrapment cover as required under the provisions of the law. Signature of Property Owner: Date: / / Signature of Contract L )• , Date: / I Signature of Building Inspector: Date; _I _l___