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•1.r..k W.GLENDALE ASE.,2ND OR
....* 3 ALE,AZ groines
C ',1 C 21s''''!..•:..-.I li':"..2 . 3.930-2aCC OWNER/BUILDER ADDENDUM
filenctikelecorn RESIDENTIAL PROJECTS ONLY
DATE COG PERMIT NIJIARFR:
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PROJECT NAME il PROJECT ADDRESS ,...).: ....,-
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the undersigned appeettneeeerte that she or he is exempt ham Me original oorttrataa,he/easing receiremere of Arizona Reamed Statham Tele 32,Chanter 10,
IN1 the ' al:
ARS:421121AI The applicant owns tte roperty end shell op:upy the pf welly,and doeS MX ililkfid Me prUperty EU be fur sale Or rent.end s,llx,
,IT,
rim the lee*performed by the applicant alone,re by thin applicant wlh r.rripOyorts or the appIcent,end/Or performed by cli,ty licensed
conract**all of atom ere idan1rhe0 terw or on the attecCed.
fl ARS 32-1121AX Inc applicant ovate tho prc.perty and shall have the Work perlOrthed°WO,'duly licensed contraotertel es.4 of%hortei are ideRited
beto at on the attacked.
— ,
CONTRACTOR/COMPANY NAME: AZ ROC RINI!ER: LICENSE CLASSIFICATION:
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0,,,,,merino 9vrnanregamone. mvswasom, ........... , ,.. e
0 ARS 32,-1121A7 The applicant i5 re•gOrAtiVd atatitect ar engineer,or employee of regricars4 eer)ntbect or engineer so wiged in protessione;
p retoe,not as a ocirdrhotor, '
IThe undersigned swears and affirms INN the informatxm herein is man and accurate,woe acknowledges that the Meg of an application containing Wee or
incorrect intonation WO the Intent to/WINO licensing of taXfaCaulternenta of the Stega of Manta IS.'ilITSALIM folodicihion".a cnrninal misderneance-
PRINTED NAME OF THE OWNER: . SIGNATURE DieTHE OWNER: /— DATE:
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