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Residential Swimming Pool Safety Affirmation

  1. For questions, contact the Building Division at (407) 262-7700 Ext. 1103 or by email at building@casselberry.org

  2. I, ________________________________________________________(print contractor's name), License Number___________________, 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 Section, Sixth Edition R4501.17.

  3. Check the applicable barrier requirements from the following options and show on the site plan:

  4. ______ The pool will be equipped with an approved safety pool cover that complies with American Society for Testing and Material F1346 (Standard Performance Specifications for Safety Covers for Swimming Pools, Spas and Hot Tubs) per Florida Building Code R4501.17, Exception.

  5. ______ The pool will be isolated from access by a mesh safety barrier that meets the requirements of Florida Building Code R4501.17.1.15.

  6. ______ The pool will be isolated from access by a screen enclosure that meets the requirements of Florida Building Code R4501.17.1.11.

  7. ______ The pool will be isolated from access by a fence and pedestrian gates that meet the requirements of Florida Building Code R4501.17.1.1 through R4501.17.1.8.

  8. Does any part of the barrier consist of dwelling walls which contain doors or windows?

  9. If yes, then check which of the three options below are applicable:

  10. ______All doors and windows providing direct access from the dwelling to the pool will be equipped with an exit alarm that meets the requirements of Florida Building Code R4501.2.17.1.9(1) unless Exceptions a, b or c apply.

  11. ______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 Florida Building Code R4501.17.1.9, Exception 2.

  12. ______A swimming pool alarm that, when placed in a pool, sounds an alarm upon detection of an accidental or unauthorized entrance into the water. Pool alarm must meet the criteria established by the American Society for Testing and Material Standard, the Florida Building Code, and Florida Statutes.

  13. I understand that the above indicated shall be installed before the time of pool safety inspection per Florida Building Code.

  14. This completed form must accompany the permit application and a copy must be kept at the job site at all times.

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