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GLEND/dE Development Group
OWNERBUILDER ADDENDUM TO BUILDING PERMIT NUMBER(S) r3110q
ADDRESS l!, Z SC4 (N
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-The undersigned applicant asserts that she or he is exempt from the original contractor licensing requirement
of Arizona Revised Statues Chapter 10, Title 32 on the basis of:
XARS 32-1121.A.5. The applicant owns the property and shall occupy the property, and does 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 identified below or on the attached.
&LARS 32-1121.A.6. The applicant owns the property and shall have the work performed only by duly
licensed contractor(s) all of whom are identified below or on the attached.
Contractor/CompanvName License Number Classification
= ARS 32-1121.A.7. The applicant is a registered architect 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 herein is true and accurate, and acknowledges that
the filing of an application containing false or incorrect information with the intent to avoid the licensing or
tax requirements of the State of Arizona is "unswom falsification," a criminal misdemeanor.
Printed Name of Owner Signature of Owner Date
City of Glendale * 5850 West Glendale Avenue.*Glendale, Arizona 85301-2599 * (602)930-2800