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Mar 03 09 08:29a Ti 209 - <br />02/26/2009 13:36 2094640. ENVIRONMENTAL HEALTI <br />d 77 <br />P..2 <br />HAUL uLluz <br />111- ?Dew( <br />Declaration <br />Property Address: (--\---‘ 1 vs-c-----c---c---,c---- <br />h<--"f•Z , 1-74:stcA -1c---) <br />Property Owner's Name (Please Print):.._..--\,----S" F'-5--.1 c ...--)r--) "\cID-- <br />)r-Q___ <br />Property Owner's Phone #:T2!--\, -7—FV)=1:71 <br />Mark all that apply to your property: <br />This property does not have a swimming pool, toddler/wader pool, or spa. <br />This iruperly does have a (check all that apply): <br />imming Pool 0 ToddlerNVader Pool El Spa <br />T e permit requested does not include any work to be performed to the swimming pool, <br />toddler/wader pool, or spa. <br />The permit requested does <br />toddler/wader pool, or spa. <br />include work to be performed to the swimming pool, <br />Contractor's License Number.7-\\\----n <br />Inspection Date(s): <br />Building inspector's Name (Please Print): <br />Anti-Entrapment Devices Installed: <br />Description <br />Drain Cover <br />Safety Vacuum Release System (SVRS) <br />Suction Limiting Vent System (SLVS) <br />Gravity Drainage System <br />Automatic Pump Shut-off System <br />Drain Disablement <br />Unblockable Drain <br />Other: <br />Classification: C5.7) <br />Date Installed <br />17X0- <br />1-13 0" 1-64.1— ovev <br />ev,i) <br />Model <br />Signature of Building Inspector: <br />lam the <br /> 0 Owner <br />Signet <br />Pleaserrin Name: <br />kl"...ontractor 0 Authorized Agent <br />Date: /..12,1t. <br />Installation Certification <br />The following certification is required whenever a building permit is issued for the <br />remodel or modification of a property's swimming pool, toddler/Wader pool, and/or spa. <br />Building Permit(s)#. <br />Contractor's Name (Please Print):C\c-c.,' #: ;-)r-.).-L4731-*D"2„, <br />Contractor's Company: <br />I. <br /> <br />Manufacturer <br />• • <br />I hereby certify that the existing swimming pool, toddler/wader pool, or spa located at the above- <br />mentioned address complies with the provisions of the 'Swimming Pool Safety Act of 2006" and <br />has been equipped with an approved anti-entrapment cover as required under the provisions of <br />the law. <br />Signature of Property Owner: Date: / / <br />V;C:=1-C's C-'( \\--.S.-----kC.- Signature of Contract - Date; _/_f <br />Date: / /