Revised 04-28-20
RESIDENTIAL SWIMMING POOL SAFETY AFFIRMATION
(Please print contractor’s name)
hereby affirm that the pool will be isolated from access from within the dwelling AND from adjacent properties by
a barrier that meets the pool barrier requirements of Florida Statute 515.29 and the 2017 Florida Building Code
Residential (6
th
Edition) R4501.17.
Check the applicable barrier requirements from the following options and show on the site plan:
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 mesh safety barrier that meets the requirements of FBC
R4501.17.1.15
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 isolated from access by a barrier and pedestrian gates that meet the requirements of
FBC R4501.17.1.1 through R4501.17.1.8
Does any part of the barrier consist of dwelling walls which contain doors or windows?
Yes ________ No ________ If "Yes," then check which of the options below are applicable:
All doors and windows providing direct access from the dwelling to the pool will be equipped with an exit
alarm that meet the requirements of FBC R4501.17.1.9(1) unless Exceptions a, b, or c apply
All doors providing direct access from the dwelling to the pool will be equipped with self-closing, self-
latching devices installed 54" above the threshold that meet the requirements of FBC R4501.17.1.9(2)
The pool will be isolated from access by a mesh safety barrier that meets the requirements of FBC
R4501.17.1.15
A swimming pool alarm that, when place in a pool, sounds an alarm upon detection of an accidental or
unauthorized entrance into the water. Such pool alarm must meet and independently certified to ASTM
Standard R2208. R4501.17.1.9(3)
I understand that the above indicated shall be installed before the time of pool safety inspection per FBC
R4501.17.1.9.
Contractor's Name (Please Print)
This completed form must be attached to the permit application and a copy
must be kept at the job site at all times.
1101 EAST FIRST STREET SANFORD FL 32771-1468 PHONE (407) 665-7050 FAX (407) 665-7486
WWW.SEMINOLECOUNTYFL.GOV
