Fillable Pool Affidavit Of Compliance Affidavit of Compliance

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Pool Affidavit Of Compliance Affidavit of Compliance

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  • 4 check-boxes
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Country of origin: US
File type: PDF

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Page 1 of 2
C:\Users\YDavis\Desktop\Pool Affidavit of Compliance 1-2-2020.docx
RESIDENTIAL SWIMMING POOL
SAFETY REQUIREMENTS
AFFIDAVIT OF COMPLIANCE
IDENTIFYING POOL BARRIER
Permit Request (PR) Number:________________Address:_____________________________________
Section R4501.17 of the 2017 Florida Building Code – Residential Volume (FBC-R), and Chapter 515, Florida
Statutes (F.S.), requires pool barriers to be installed around the entire perimeter of a pool, spa or hot tub. In
addition to this executed affidavit, all provisions for the required pool barrier shall be shown on the plans.
I/we acknowledge that a swimming pool, spa or hot tub exists or will be constructed or installed at the above
address, and hereby affirm that one or more of the following methods will be used to meet the requirements
of the Section R4501.17 of the 2017 FBC-R and Chapter 515, F.S.
Please check applicable method used to create a 360-degree barrier around pool, spa or hot tub:
A. The pool will be equipped with an approved safety pool cover that complies with ASTM F1346-
91(2010), Standard Performance Specifications for Safety Covers for Swimming Pools, Spas and Hot
Tubs.
B. A new, continuous barrier, such as a fence, wall or screen enclosure, will be placed completely
around the pool perimeter to provide the required 360-degree protection. Identify method below and
on site plan or pool layout:
*Please check only one
Four foot or higher perimeter fence (wood, chain link, aluminum, PVC or other).
Aluminum screen enclosure with self-closing, self-latching door with a latching device that is
a minimum of 54 inches above the threshold.
Child safety barrier meeting Section R4501.17.1.15 of the 2017 FBC-R.
Other (specify) ______________________________________________
C. A combination system such as a perimeter (partial) barrier used in conjunction with a child safety
barrier between house and pool meeting Section R4501.17.1.15 of the 2017 FBC-R, window/door
alarms meeting UL 2017 and Section R4501.17.1.9 of the 2017 FBC-R, or window alarms with doors
meeting self-closing, self-latching requirements of Section R4501.17.1.9 of the 2017 FBC-R
or
certified swimming pool alarms meeting the requirements of Section R4501.17.1.9 2017
FBC-R. Identify proposed combination below AND identify on site plan or pool layout.
Screen enclosure with (choose one):
o Child safety barrier between house and pool; or
o Window and door alarms (or complying doors) at required locations (indicate type of
alarm and who is installing); or
o Swimming pool alarm independently certified to ASTM Standard F2208 , which
includes surface motion, pressure, sonar, laser, and infrared
alarms
Palm Beach County
Planning, Zoning & Building
Building Division
Initial Here
Page 2 of 2
C:\Users\YDavis\Desktop\Pool Affidavit of Compliance 1-2-2020.docx
Perimeter fence with (choose one):
o Child safety barrier between house and pool; or
o Window and door alarms (or complying doors) at required locations (indicate type of
alarm and who is installing); or
o Swimming pool alarm independently certified to ASTM Standard F2208, which
includes surface motion, pressure, sonar, laser, and infrared alarms
Existing four foot or higher perimeter privacy fence converted (with permit) to pool barrier
fence with:
o Child safety barrier between house and pool; or
o Window and door alarms (or complying doors) at required locations (indicate type of
alarm and who is installing); or
o Swimming pool alarm independently certified to ASTM Standard F2208 , which
includes surface motion, pressure, sonar, laser, and infrared alarms
o Some or my neighbor’s entire fence is used as the required barrier. I understand
there are additional requirements associated with this option because the barrier is
located on adjacent property. A POOL BARRIER AGREEMENT IS REQUIRED
o Other (please specify)
________________________________________________________________
________________________________________________________________
I understand that not having, and not maintaining, a complete barrier around the perimeter of the pool is a
violation of Section R4502.17.1 of the 2017 FBC-R, which may be prosecuted through the Palm Beach
County Code Enforcement Division.
I further understand that filling a pool with water before passing a final electric inspection and final barrier
inspection by Palm Beach County is a violation of Section 109.3.A.6 of the Florida Building Code, as amended
by Palm Beach County. The Building Division will consider these violations willful and will commence the
appropriate disciplinary actions against those responsible.
____________________________________ ____________________________________
Owner’s Signature and Date Owner’s Name (Please Print)
STATE OF FLORIDA
COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me by means of □ physical presence or □ online
notarization, this ______________ day of _____________________________________, 20__________
by , □ whom do I personally know or □ who has
Name of Person Acknowledging
produced as identification and who did/did not take an oath.
Type of I.D.
SEAL
_____________________________________ _____________________________________________
(Signature of person taking acknowledgement) (Name of officer taking acknowledgement typed, printed
or stamped)
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Pool Affidavit Of Compliance Affidavit of Compliance

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Completed 9 June 2020

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