PERMIT DOCUMENTS 7C2;-1)/ti .
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CITY OF BOYNTON BEACH
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DEVELOPMENT DEPARTMENT BUILDING DIV.1SION
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Boynton Beach Boulevard•Boynton Beech,FL 33435 (561)742-6350•Fax 742-6357
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ro•N 0�P AolcREINSTATEMENT APPLICATION FOR: ❑ EXTENSION
SELECT ONE: ❑ Permit ❑ Permit Application (max of(3) three extensions)
Project Name: OMR/ /ko gl
Permit # / 3 , w/(is Job Address: Qs S- Air, Ave C
Contractor of Record: 170eiern /4-c- )`
Phone: Z/ (- 732-Z3 yy Email: rpOe in,AG/ a,97,
Mailing Address: 02300 N- o&/ i)i K/C9g le 35777City �-,4ea4State: ✓�, Zip Code:y3r</fre
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Detailed reason for a extension:
/No c A A acrenOW1W-, fdl" knit , /111iQ•r.WOn /apAdvmSe5V
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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.
Qualifier/Authorized Agent i , E10 a -/5---/9'
Signature Date
Printed Name
FOR OFFICIAL USE ONLY
Date of Expiration: J6/fi/i5 Processing Technician Initials:
Application Extension(max of(3)three extensions): 0151$50.00 ❑2nd$75.00 03rd$100.00
Permit Extension: 01"$50.00 ❑2nd$75.00 ❑3rd$100.00 ❑Extension beyond 90 days$250.00(Requires
Building Board of Adjustment&Appeals Approval)
Permit Reinstatement Fee: Total Permit Value: 5cR CIS--
Times
ISTimes 2.3%
Under 180 days of inactive status ❑ 75 0. 7r./ / (
Over 180 days of inactive status E ..$75.00 • Permit Fee: 7 CPi
Over 180 days of inactive status ........3,'•n Times 30%
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(�e�(Whichever is greater) Reinstatement Fee: c2a. 3
ifpproved,extended for l v ays ❑ Denied **Additional I pact Fees may apply
2 2-1/4 ))
Reviewe y Building Official Date
S:\Development\BUILDING\Forms-Templates-Signs\Application for Extension-REVISED 1-20-2016.docx