PERMIT DOCUMENTS ; 4,
CITY OF BOYNTON BEACH
DEVELOPMENT DEPARTMENT I BUILDING DIVISION
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C 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fax 742-6357
oAPPLICATION FOR: D EXTENSION Q **REINSTATEMENT
SELECT ONE: ❑ Permit ❑ Permit Application (max of(3) three extensions)
Project Name:
Permit # _ 3ro6 Job Address: 33 0 E a t ave 208 £'3
Contractor of Record: . < •SLrtf nJ X•-12p +t i AX •
Phone: it —73 y— Of b7 Email: kms -m S L tCe tJ PO [. (OM
Mailing Address: inn St.0 i o t& a,,,-Q_ f
City Qo r.40...) 13-e State: Zip Code: 3z yz6
Detailed reason for the extension: C!J S-k—cutA )s td E-to r^
rein, ka.Ck
I, the undersigned, am requesting an extension/reinstatement for the item indicated above. I understand that
submittal of this form does not constitute in its approval ofthe e/xxtension/reinstatement,
Qualifier/Authorized Agent /y(/(,`1(__ 3 J A j-Z
Signature / to
•ernJN-C+k ItiIVLc_r
Printed Name
FOR OFFICIAL USE ONLY /j
Date of Expiration: 3/5-1/4 ( Processing Technician Initials:
Application Extension(max of(3)three extensions): ❑1'$50.00 02nd$75.00 ❑3rd$100.00
Permit Extension: 013'$50.00 02nd$75.00 03rd$100.00 ❑Extension beyond 90 days$250.00(Requires
Building Board of Adjustment&Appeals Approval)
Permit Reinstatement Fee: Total Permit Value: ) I .
Under 180 days of inactive status X. 75.00 Times 2.3% (26 (Z
Over 180 days of inactive status ❑...........$75.00 or Permit Fee: UY
Over 180 days of inactive status 0 30% Times 30% Cl
(Whichever is greater) Reinstatement Fee: r�
® Approved,extended for r30 says ❑ Denied **Additional Impact Fees may apply
trer-
3/io/i7
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vie et • : :mg Official Date
S:\Development\:r ILDING\Form- emplates-Signs\Application for Extension-REVISED 1.20-2016.docx