G:\Zoning 2009\Forms and Sample documents\Website Documents\Building\Forms\pool_affidavid.pdf Modified: 08.25.2017
City of Pompano Beach
Department of Development Services
Building Inspections Division
Application #______________________
100 W. Atlantic Blvd Pompano Beach, FL 33060
Residential Swimming Pool, Spa and Hot Tub Safety Act
Phone: 954.786.4669 Fax: 954.786.4677 Notice of Requirement
I (We) acknowledge that a new swimming pool, spa or hot tub will be constructed or installed at (Print Job Address)
and hereby affirm that one or more of the following methods will be used to meet the requirements of Chapter 515,
Florida Statues and Florida Building Code Section 454.2.17
Please initial the method(s) to be used for your pool or spa:
__________The pool will be equipped with an approved safety pool cover that complies with ASTM F1346 (Submit Manufacturers
Specifications).
__________A continuous, one-piece (child) barrier meeting the requirements of Florida Building Code 454.2.17 will protect the pool
perimeter. The plans shall show the fence location and method of attachment, including one end that shall not be
removable without the aid of tools. (Submit Manufactures Specification).
__________A combination of non-dwelling walls and fences (screen enclosure, masonry fence walls, chain link or wood fence, etc.)
will protect the pool perimeter (pool deck). The plans must specify the type and location of all non-dwelling walls.
__________Any combination of protection which incorporates dwelling walls with openings directly into the pool perimeter, and all
windows and doors will be equipped with exit alarms complying with Florida Building Code, 454.2.17.1.9 (Submit
Manufacturers Specifications)
__________Any combination of protection which incorporates dwelling walls with openings directly into the pool perimeter and all
doors will be equipped with a self-latching device with positive mechanical latching/ locking installed a min. 54"
above the threshold. If this option is selected, submit plans showing all types and location of all perimeter protection.
The plans must also show the location and type of all openings, and the hardware type for each location. (Submit
Manufactures Specifications)
__________A swimming pool alarm that, when placed in a pool, sound an alarm upon detection of an accidental or unauthorized
entrance into the water. Such pool alarm must meet and be independently certified to ASTM Standard F2208.
In accordance with the Code, a final inspection of the pool project will not be approved without compliance with the Private
swimming Pool Safety Requirements, and upon expiration of the permit, the pool shall be presumed to be unsafe. PER FBC 116.
I understand that not having one of the above installed 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 Section 775.082 or Section 775.083 F.S. This form must
be signed by the owner/ agent and the prime contractor.
_____________________________________________
Signature of Legal Owner / Agent
STATE OF FLORIDA- COUNTY OF
BROWARD
Sworn to (or affirmed) and subscribed before me
this ______ day of ______________. 20 _____ by
_____________________________________________
Type / Print Owners / Agents’ Name
_____________________________________________
NOTARY'S Signature as to Owner / Agent Signature
____________________________________________
NOTARY'S Name & Title (print/ typed/ or stamped)
Personally Known _______ or Produced Identification ______
Type of Identification Produced:
_________________________________________________
_____________________________________________
Signature of Legal Contractor
STATE OF FLORIDA- COUNTY OF
BROWARD
Sworn to (or affirmed) and subscribed before me
this ______ day of ______________. 20 _____ by
_____________________________________________
Type / Print Contractor’s Name
_____________________________________________
NOTARY'S Signature as to Contractor Signature
_____________________________________________
NOTARY'S Name & Title (print/ typed/ or stamped)
Personally Known _______ or Produced Identification ______
Type of Identification Produced:
_________________________________________________
