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GLENTE4gE Development Group
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OWNER/BUILDER ADDENDUM TO BUILDING PERMIT.NUMBERM_ r
ADDRESS (b_:__),aLAt\\__\CAMCILy- 64,r. (6, 4
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'The undersigned applicant asserts that:she or.he is exempt frem the original contractor licensing requirement
Of Arizona Revised Statues Chapter 10,Title 32 an the hati
IXARS 32-1121.A.5. The applicant owns the property and Shall occupy the property, and dor not intend
the property to be for sale or rent, and shall have the work performed by the applicant alone, or by the
applicant with employees of the applicant,and/or performed by duly licensed contractor(s)all of whom
are identined below&On ther:attached.
— 32-1 121.A.6. The applidant owns the property and shall have the work performed only by duly
licensed contractor(s)all of whorn are identified below or on the attathed.
Contractor/Company Name License Number
Arks 32-112I.A.7. The applicant is a registered 4rek4teat or engineer, or employee of registered
architect or engineer engaged.in professional.practice,not as a contractor.
The undersigned swears and affirms that the information hereui is true and accurate, and acknowledges that
the filing of an application containing false or incorrect infortnation with the intent to avoid the licensing or
tax requirements of the State of Arizona is"unsworn falsification,"a.criminal misdemeanor.
Printed Name of Owner Signatureofftwner vat
City of Glendale * 5850 West Glendale Ayentte,*elencialt,t,Arizona g53,01-2594 *002)930-280