HomeMy WebLinkAbout117667 rms/It CITY OF GLENDALE
Will PLANNING&DEVELOPMENT SERVICES
5850 W.GLENDALE AVE.,2ND FLOOR
GLENDALE, 85301 OWNER/BUILDER ADDENDUM
Glendale 623.930.30.280800
ARIZONA www.GlendaleAZ.com RESIDENTIAL PROJECTS ONLY
DATE: COG PERMIT NUMBER: I I
/
PROJECT N PROJECT ADDRESS:
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-1k/f.4-c.) / ?" Z/d. (26214roo Ai.e.‘ dr)
The undersigned applicant asserts that she he is exempt from the original contractor licensing requirement of Arizona Revised Statutes Title 32,Chapter 10,
on the lh�is of:
ARS 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.
❑ ARS 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/COMPANY NAME: AZ ROC NUMBER: LICENSE CLASSIFICATION:
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❑ ARS 32-1121.A.7 The applicant is 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 licensing or tax requirements of the State of Arizona is"unsworn falsification",a criminal misdemeanor.
PRINTED NAME OF THE OWNER: SIGNATURE OF THE OWNER: DATE: