PERMIT DOCUMENTS
CITY OF BOYNTON BEACH
DEVELOPMENT DEPARTMENT | BUILDING DIVISION
100 East Boynton Beach Boulevard • Boynton Beach, FL 33435 • (561) 742-6350 • Fax 742-6357
APPLICATIONFOR:EXTENSIONREINSTATEMENT
SELECT ONE:PermitPermit Application (max of (3) three extensions)
Project Name: ____________________________________
Permit # Job Address:
Unit #
219
2991!O!Dpohsftt!Bwf
2:.5834
Contractor of Record:
Phone:
Email:
672.524.6:1:disjt/hbmmfhpAtujmft/dpn
Mailing Address:
2611!Hbufxbz!Cmwe
City State: Zip Code:
Gmpsjeb
44537
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Detailed reason for the extension:
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I, the undersigned, am requesting an extension/reinstatement for the item indicated above. I understand that
submittal of this form does not constitute in itself approval of the extension/reinstatement.
Ejhjubmmz!tjhofe!cz!Disjt!Hbmmfhp
EO;!do>Disjt!Hbmmfhp!pv>Qspqfsuz!Nbobhfnfou!f>Disjt/HbmmfhpAtujmft/dpn
Sfbtpo;!J!bn!uif!bvuips!pg!uijt!epdvnfou
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Disjt!Hbmmfhp
2302103131
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Qualifier:
Signature Date
DisjtHbmmfhp
Printed Name
FOROFFICIALUSEONLY
DateofExpiration:ProcessingTechnicianInitials:________
stndrd
ApplicationExtension(maxof(3)threeextensions):1$50.002$75.003$100.00
stndrd
PermitExtension:1$50.002$75.003$100.00Extensionbeyond90days$250.00(Requires
BuildingBoardofAdjustment&AppealsApproval)
PermitReinstatementFee:
TotalPermitValue:______________________
Times2.3%
Under180daysofinactivestatus
PermitFee:______________________
Over180daysofinactivestatusor
Times30%
Over180daysofinactivestatus
ReinstatementFee:______________________
(Whicheverisgreater)
Approved,extendedfor_________daysDenied**AdditionalImpactFeesmayapply
2302103131
________________
ReviewedbyBuildingOfficialDate
S:\\Development\\BUILDING\\FormsTemplatesSigns\\ApplicationforExtensionorReinstatement.docx