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V er. ` GEORGE R FE''rNE�
s �" CITY OF GLENDALE v.�yira
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5650 West Glendale Avenue RK AO BEI .
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/�IZO�Tr Gtenda1e,Arizona 85301 ROBERT E r' kJ.
(602)a35•4000 HOG
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DECLARATIONS. Check the appropriate box, complete the required
information in the selected declaration, sign and date.
CONTRACTOR
LICENSED. I hereby affirm that the applicant is currently
licensed under the provisions of ARS Title 32 , Sec. 32-1101
through Sec. 32-1198 .
Lib. No. State Tax Lic. No.
E3 'TION. I hereby affirm that the applicant is exempt from_ _
licensing for the following reason.
GOVERNMENTAL. Agency of the U.S . Government, State of
. Arizona, County, Municipality or Political Subdivision.
(ARS Sec. 32-1121.A.1) .
OWNER/BUILDER_ Improving owner (s) property themselves or
jointly with licensed contractors and said improvements are
not for sale or rent (ARS Sec. 32-1121.A. 5) .
RESIDENTIAL OWNER. Owner(s) of residential property using
only licensed contractors (ARS Sec. 32-1121.A. 6) .
. ARCHITECT/ENGINEER. Engaging in professional .practice as
defined in ARS Title 32 , Chapter 1, and not engaging in
contracting (ARS Sec. 32-1121.A. 7) .
OTHER.
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Signature I--t-�,� Z,(, Date f/ - K-- 47/
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FOR DEPARTMENT USE ( 1LY
Permit(s) � j 7 ? L )
Single statement may be used for consecutively numbered permits .