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OWNER/BUILDER ADDENDUM
OWNER/BUILDER ADDENDUM TO BUILDING PERMIT NUMBER(S) 1400
ADDRESS 7/,4 g 0 '1716 441 , Y Gc lev‘d4-'e A Z ?53U1
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:
— 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 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 "unsworn falsification," a criminal misdemeanor.
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Printed Name of Owner Signature of Owner t/k Date
a/a bi‘
City of Glendale
Development Services•5850 West Glendale Avenue•Glendale,Arizona 85301-2599• Phone(623)930-2800
www.glendaleaz.com
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