PERMIT DOCUMENTS ti-
OF BOYNTON BEACH
m = DEVELOPMENT DEPARTMENT I BUILDING DIVISION
o v 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fax 742-6357
7'ON O
APPLICATION FOR: El EXTENSION La **REINSTATEMENT
SELECT ONE: ZyPermit ❑ Permit Application(max of(3) three extensions)
Project Name: 2e-inciCSSGt rnG2�
Permit # I[-100002SD I Job Address: Iti,(0Q 2C ,S5av Ce— GrAmmenns i3/Qd ZI )8
Contractor of Record: S\u"?1cx & y'tu' �\
Phone: S4 I 2-7 7 y l y o Email: cif .579 74S—C1>C Aris
Mailing Address: 1E30 Pat-lt Lin J u , •a t-
City J �'1� State: FR_ Zip Code:
Detailed reason for the extension:
\ l )) Inn �
I); no+ �P� dZo �. , s1�c. ,ate. -
n
JL�Si e P CY-P
I, the undersigned, am requesting an extetsion/rei atement for the item indicated above. I understand that
submittal of this form does not constitute i it •If a:royal of the e - sion/reinstatement.
Qualifier/Authorized Agent / - 3/Z 3//G
Signature Date
int\S Ac4c �S
Printed Name
FOR OFFICIAL USE ONLY
Date of Expiration: ��—/(9 Processing Technician Initials:
Application Extension(max of(3)three extensions): 015`$50.00 02nd$75.00 03rd$100.00
Permit Extension: 01"$50.00 02nd$75.00 El 3rd$100.00 ❑Extension beyond 90 days$250.00(Requires
Building Board of Adjustment&Appeals Approval)
Permit Reinstatement Fee: Total Permit Value:
Under 180 days of inactive status $75.00 Times 2.3%
Over 180 days of inactive status ❑ $75.00 or Permit Fee:
Over 180 days of inactive status ID30% Times 30%
(Whichever is greater) Reinstatement Fee:
Approved,extended for 90 days 0 Denied **Additional Impact Fees may apply
icy ,/2tin
Review d b Bui din: Official Date
S:\Development\BUILDING\Forms-Templates-Signs\Application for Extension-REVISED 1-20-2016.doa