HomeMy WebLinkAbout200036 6-00 3
CIT :OF GLENDALE
PLANNING&DEVELOPMENT.SERVICES It E.C E �.E D,
5850 W:GLENDALE AVE.,2ND FLOOR
GLENDALE;AZ.85301.
JAN 03 2020
Glendale fi23.939.2800 OWNER/BUILDER ADDENDUM
a www.GlendaleAZ.com
DEVELOPMENT T
RESIDENTIAL PROJECTS ONLY
DATE COG PERMIT NUMBER:.
PROJECT NAME: : PROJECT.ADDRESS: ' .
al .z . . Ro 5
� s
The undersigned applicant asserts that she or he is exempt from the original contractor licensing requirement of Arizona.Revised Statutes Title 32,Chapter 10,
on the_basis o .. .
�: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
contractors)all of whom are identified below or on the attached..
: • 0 'ARS32-1121.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:
•
0 ARS 32-1121.A:7 The applicant is registered architect or engineer,:oremploye_e,of registered architect or engineer engaged in professional
. . .practice,-not as a;contractor. .
The undersigned-swears and-effirms-inattthe-lriiormation herein is true and accurate;and-acknowledges that the filing of en 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: