Laserfiche WebLink
Signet <br />Pleaserrin Name: I <br />Model Date Installed Manufacturer <br />of <br />py6 1.,,e7k/k tz, LA) r c_64761---oJev (kV <br />ileA( irv9.6. <br />Mar 03 09 08:29a T <br />02/26/2009 1.3:36 2094640 <br />2091439 77 <br />ENVIRONMENTAL HEAL T <br />P.2 <br />tut/ vz <br />111 — 6 e oy <br />Declaration <br />Property Address:(--...\--‘(---*\ \P"C"),C---Cmc <br />h<ThC,z:c\ .r`,—C9---, (74s, C-4 <br />Property Owner's Name (Please Print): .:_.--\\ ''S-CtTh sncffTh '-) r--)C,6\CITS 410161fg____ <br />Property Owners Phone #:T;;2'-)-2_\--k.:-----Pc1-1 •r-4::)._, L."7-u,Ly\cj(2s. <br />A.-----C___ Mark all that apply to your property: <br />0 This property does not have a swimming pool, toddler/wader pool, or spa. <br />O This iroperty does have a (check all that apply): <br /> imming Pool 0 Toddler/Wader Pool 0 Spa <br />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 include work to be performed to the swimming pool, <br />toddler/wader pool, or spa. <br />I arc the 0 Owner kl:htra dor <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 QC #: <br />Contractor's Company: <br />Contractor's License Number \\(\ <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 />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: _/j <br />Signature of Contractor.-.. . Date; / <br />Signature of Building Inspector: Date: _I _I _ <br />(3 Authorized Agent <br />Date: <br />Classification: