City of Clermont
RESIDENTIAL SWIMMING POOL
SAFETY AFFIRMATION
A COPY OF THIS FORM MUST BE POSTED ON THE JOB SITE AND THE ORIGINAL IS REQUIRED
TO BE TURNED IN AS PART OF THE APPLICATION PACKAGE
_________________________
Permit #
I (we) acknowledge that a new swimming pool, will be constructed or installed at (please print street
address) ___________________________________________________________, and hereby affirm
that one of the following methods will be used to meet the requirements of Chapter 515, Florida Statutes.
Check the applicable barrier requirements from the following options and show on the site plan;
_____The pool will be isolated from access by a screen enclosure that meets the requirements of FBC
R4501.17.1.11.
_____The pool will be equipped with an approved safety pool cover that complies with ASTM F1346 (Standard
Performance Specifications for Safety Covers for Swimming Pools, Spas and Hot Tubs) per FBC R4501.17,
Exception
_____The pool will be isolated from access by a fence and pedestrian gates that meet the requirements of FBC
R4501.17.1.1 through R4501.17.1.14.
_____The pool will be isolated from access by a mesh safety barrier that meets the requirements of FBC
R4501.17.1.15
Does any part of the barrier consist of dwelling walls which contain doors or windows?
YES________
NO________
If you checked “YES” to the above question, indicate which one of the following options is applicable.
_____All doors and windows providing direct access from the dwelling to the pool shall be equipped with an exit
alarm that meets the requirements of FBC R4501.17.1.9 (1)
_____All doors providing direct access from the dwelling to the pool must be equipped with self-closing, self-latching
devices installed a minimum of 54” above the threshold that meet the requirements of FBC R4501.17.1.9 (2)
_____A floating pool alarm that meets and is independently certified to ASTM Standard F2208 will be
provided per FBC R4501.17.1.9 (3)
I understand that not having one of the above insta lled at the time of final inspection, or
when the pool is completed for contract purposes, will constitute a violation of Chapter
515, F.S. and will be considered as committing a misdemeanor of the second degree,
punishable as provided in s.775.082 or s. 775.083.
________________________________ ______________________________
Contractor's Signature and Date Owner's Signature and Date
________________________________ ______________________________
Contractor's Name (Please print) Owner's Name (Please Print)
2-6-2020
