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 #
55B
5586!O!Pdfbo!Cmwe
2:.5167
Contractor of Record:
Bmm!Tubs!Qmvncjoh!boe!Esbjo!Dmfbojoh!Jod
Phone:
Email:
672.778.3:11bmmtubsqmvncjohAcfmmtpvui/ofu
Mailing Address:
566!O!Ibwfsijmm!Spbe!
City State: Zip Code:
Gmpsjeb
Xftu!Qbmn!Cfbdi!44528
Detailed reason for the extension:
offe!up!dbmm!jo!gps!b!gjobm!
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.
210803132
Qualifier:
Signature Date
Spz!F!Cvti
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%
Under180daysofinactivestatusͶͶͶ͵͵υАЎ͵ЉЉ
PermitFee:______________________
Over180daysofinactivestatusͶͶͶ͵͵υАЎ͵ЉЉor
Times30%
Over180daysofinactivestatusͶͶͶ͵͵ЌЉі
ReinstatementFee:______________________
(Whicheverisgreater)
Approved,extendedfor_________daysDenied**AdditionalImpactFeesmayapply
210803132
________________
ReviewedbyBuildingOfficialDate
S:\\Development\\BUILDING\\FormsTemplatesSigns\\ApplicationforExtensionorReinstatement.docx
CITY OF BOYNTON BEACH
DEVELOPMENT DEPARTMENT | BUILDING DIVISION
100 East Boynton Beach Boulevard --6357
_____________________________________________________________________________
WATER HEATER CHANGE-OUT
The applicant is required to complete this form in order to receive a turn-around permit for an Exact Water
Heater Change-Out.
Spz!F!Cvti
_______ I affirm that either a representative of my company or I have inspected the existing conditions
and there is no upgrade of the electrical system or service wiring changes required for the new unit(s)
being installed. I also affirm that there is an electrical disconnect within sight and the water heater
is not cord-receptacle connected, meeting the requirements of 2011 NEC, Article 422 inclusive.
An electrical sub-permit may be required for any additional electrical work. All work shall comply
with the 2011 NEC.
Print legibly or type and fill out form completely.
)672*!383.6161
Permit Number:
New unit will be installed in what type of facility (check type of facility or fill in Other):
Y
Single-family Other
Multi-family
Commercial
Industrial
5586!O!Pdfbo!Cmwe!$55B
Job Address: (including unit number and gate code, if applicable)
Existing unit information:
B0P!Tnjui4611
Make of Unit Total Watts of Each Unit
51
Size (Gallons) Heat Recovery Unit Yes No
Proposed new unit information:
B0P!Tnjui!4611
Make of Unit Total Watts of Each Unit
51
Size (Gallons) Heat Recovery Unit Yes No
Fousz!Ibmm!Dmptfu
Location of Water Heater:
I certify that the information entered on this form accurately represents the system installed.
Qualifier or (print) License No.
Spz!F!CvtiDGD2537388
Signature: Phone No.
672.778.3:11
672.829.64:9
Cell Phone
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561) 742-6350 Fax: (561) 742-6357
S:\\Development\\BUILDING\\Forms-Templates-Signs\\Water Heater Change Out Form 8-2015.docx
(11/00,12/00,1/01,4/01,6/02,12/02,1/03,4/03,6/03,7/04,12/06,7/07,8/07, 01/09, 04/09, 01/10; 08/15)