PERMIT DOCUMENTS 31 \ n
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�t�jCITY OF BOYNTON BEACH
DEVELOPMENT DEPARTMENT I BUILDING DIVISION
v 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fax 742-6357
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Ton
APPLICATION FOR: E EXTENSION Nr **REINSTATEMENT
SELECT ONE: S Permit ❑ Permit Application(max of(3) three extensions)
Project Name: CJka A�es,c\enc• e.
Permit # 16_00O0ntog Job Address: rimW a± s4rceA 33c_i o
Contractor of Record: kSu-S4t.ts —Korz n & C—C,L3 v As
Phone: 5(e(-1q,305c. Email: cc0.S1,@ CtuLSjscusr ,eamiean,.
Mailing Address: \ \y's w S.nd•,es Ln
City J \Qr State: rL ` Zip
`Code: 334b9
((Deet�tailed reason for the extension: E rn ci e e asst n Sem A J �^� S 'F cck< W0.s
Fir ioCC o- `eNr«'m0.Ace . , . Ob%ious\V •
I, the undersigned, am requesting an extension/reinstatement for the item indicated above. I understand that
submittal of this form does not consti ,ie'1 itsetf approval`of the extension/reinstatement.
Qualifier/Authorized Agent va
�1 1 1) � p/�
/ - n- I n
Signature Date
SCAVNC O-S. -R1 ge S.
Printed Name
FOR OFFICIAL USE ONLY �
Date of Expiration:/6l/o� bCp Processing Technician Initials: '(VJ/Yl—.
Application Extension(max of(3)three extensions): ❑1"$50.00 02n°$75.00 03'd$100.00
Permit Extension: 01 $50.00 ❑2nd$75.00 03rd$100.00 ❑Extension beyond 90 days$250.00(Requires
Building Board of Adjustment&Appeals Approval)
Permit Reinstatement Fee: Total Permit Value: /Or OC
Under 180 days of inactive status $75:00 Times 2.3%
Over 180 days of inactive status ❑ $75.00 or Permit Fee: 3e) U
Over 180 days of inactive status '❑ 30% Times 30% (pq,Oa
(Whichever is greater) Reinstatement Fee: O°
Approved,exte • • . CC days ❑ Denied **Additional Impact Fees may apply
carat. 02/,7/, 7
/viewe• Cuilding Official Date
S:\Development\BUILDING\F•rms-Templates-Signs\Application for Extension-REVISED 1-20-2016.doa
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City of Boynton Beach
Building Division
LICENSED ROOFING CONTRACTOR
AFFIDAVIT
ROOF METAL & ROOF SHEATHING INSTALLATION
(EXISTING DETACHED ONE & TWO FAMILY DWELLINGS ONLY)
The City of Boynton Beach offers progressive inspections— call 742-6355
To: City of Boynton Beach, Florida
Department of Development- Building Division
Field Inspection Section
100 East Boynton Beach Blvd., PO Box 310
Boynton Beach, FL 33425-0310
Re: Permit No. 16-00001764
From: Augustus Roofing and Consulting, Inc (Contractor)
19415 W Indies Ln Jupiter, FL 33469 (Contractors Address)
Peter Culhane (Owner/s Name)
1708 SW 21st Street 33426 (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
*Certification of roof metal installation, flashing, underlayment.
;;Certification of re-nailing roof sheathing, and removal and replacement of damaged or rotted wood.
-Other Stone Coated Steel Metal Installation
C 'J
I. F. Faith Cash , am certified as a roofing contractor (License No.
CCC1330214 ) and do hereby certify that all roof work (as indicated above) has been performed
at the above address in accordance with Chapter 15 of the Florida Building Code, Existing Building, as
amended, and Manufacturer's Specifications. I understand that the City of Boynton Beach offers progressive
e-`I
I . so!st9i �� I,t�vee ngtiff a owner of the property of this affidavit.
2nn7
of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH � 1
The foregoing instrument was acknowledged before me this o211111- (date)by F. f01(lh Cn& 1 , who
is personally known to me or who has produced F I 1DrIV-PV U('-nse (type of identification)as identification
and who did (did not)take an oath.
Signature of person taking acknowledgement , SAVIEA fl00PIAL
a ": '.�-; Notary Public-Slate of Floritla
Name of officer taking acknowledgement--typed, printed or stamped gf My Comm.Expires May 29.2018
`t �, '" , f '.;.,,,i I3 Commission t' FF 127607
Title or rank t4thl lX 11�UJl IC Serial number
J _ na - n
100 East Boynton Beach Blvd,PO Box 310,Boynton Beach FL 33425-0310 Phone: (561)7424350 Fax:(561)7424357
SADevelopmentlauilding1Forma Templates1RoofingMetal&SheathinglnstallationPolicy&AfidavR-182ramily(12/99,12102,1/03.1003,11/059/06, 04/09,
7/12)