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Mar 03 09 08:29a T 02/26/2009 13:36 2094640 2092 4 96877 ENVIRONMENTAL HEALT) 1-'441.3t P • riz 2 I am the El Owner Signet PleaseTrrin Name: kI:oritractor O Authorized Agent Date: .L1 12_,.1( FoiL , 4- 5ee& 04 job Manufacturer Model - ' 17 Xt1 L-P Date Installed ZIYa6 Vet ( num- Declaration Property Address: Property Owner's Name (Please Print): c 4 '-c__ Property Owner's Phone #:FLP_--k -7--Fkrf_71 Mark all that apply to your property: This property does not have a swimming pool, toddler/wader pool, or spa. fl This roperty does have a (check all that apply): imming Pool D ToddlerNVader 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, toddlerfwader pool, and/or spa. Building Permit(s) Contractor's Name (Please Print): Contractor's Company: Contractor's License Number=:--\--A,C=F-\--D Inspection Date(s): Building Inspector's Name (Please Print): 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 Pool 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 \r'P)i-Css , Date. / Signature of Building Inspector: Date: / *4' hone #: Classification: