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PERMIT DOCUMENTS 349-i c%,„ 0.e.- CITY OF BOYNTON BEACH mc= DEVELOPMENT DEPARTMENT BUILDING DIVISION ION t, 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fax 742-6357 Iv TON 0 APPLICATION FOR: ❑ EXTENSION ❑ **REINSTATEMENT SELECT ONE: ❑ Permit ❑ Permit Application(max of(3) three extensions) Project Name: Permit # Vic`.-000sa561 Job Address: 5 ( 1 C 0060 41-- 4,-,./ Contractor of Record: Acreigeo A. CoN e 0,,,� Phone: ,5 c a3‘ SSS Email. a S dP y4- 440Ge---- Mailing Address'. s s€ 0.,,,e/6, s f '5r City L kr- State: r'"G' Zip Code: ' Ye-7 Detailed reason for the extension: 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 c2 3 /7 , Signature a Date /T / / �C,-C, 1. C Printed Name FOR OFFICIAL USE ONLY Date of Expiration: U�U6 Processing Technician Initials: -" Application Extension(max of(3)three extensions): Dig$50.00 02nd$75.00 ❑3r°$100.00 Permit Extension: ❑1'$50.00 ❑2n0$75.00 03rd$100.00 ❑Extension beyond 90 days$250.00(Requires Building Board of Adjustment&Appeals Approval) Permit Reinstatement Fee: Total Permit Value: 1-620a — Under 180 days of inactive status ❑ $75.00 Times 2.3% �n/' // (O Over 180 days of inactive status ❑ K$75.9r Permit Fee: ! (Q Over 180 days of inactive status ..........311% Times 30% C (Whichever is greater) Reinstatement Fee: tT t Approved,extended • c30 days ❑ Denied **Additional Impact Fees may apply a ©Z/23//7 Reviewer • : r 1 ding Official Date S:\Development\BUILDING\F.rms-Templates-Signs\Application for Extension-REVISED 1-20-2016.docx