PERMIT DOCUMENTS L\T Y t,
+ CITY OF BOYNTON BEACH
DEVELOPMENT DEPARTMENT I BUILDING DIVISION
oki t= 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fax 742-6357
TON 0
APPLICATION FOR: ❑ EXTENSION L*REINSTATEMENT
SELECT ONE: ErPermit ❑ Permit Application (max of(3) three extensions)
34. 5 5 Project Name:
Permit # 16 - 3 Y Job Address: c/7 7X Canj2a1 /ue .
Contractor of Record: pA
606) 7R„icz�a
Phone: giyA6L - yY6, Email: Spm&c e Poen CuC?ap,i3,•z
Mailing Address: 6 0 6 o 13,--A,7 Qr7
City LAM c cAA A,-A State: fc, Zip Code: 33`r6
Detailed reason for the extension: C
n 1 CG'S ?if 70 6 e f/Pnd f(-7..,#k
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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 f the extension/reinstatement.
Qualifier/Authorized Agent `: '" �'/ .15/2.25-A
Signature Date
SSA-, r
Printed Name
FOR OFFICIAL USE ONLY I
Date of Expiration: 41 I" f (1 Processing Technician Initials: A
Application Extension(max of(3)three extensions): ❑1"$50.00 ❑2nd$75.00 ❑3`d$100.00
Permit Extension: Oft$50.00 02s$75.00 ❑3`d$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 El 575.00 or Permit Fee:
Over 180 days of inactive status ❑ 30% Times 30%
(Whichever is greater) Reinstatement Fee:
AApproved,extended for `J days ❑ Denied **Additional Impact Fees may apply
Sli5(
Reviewed by Building Official Date
S:\Development\BUILDING\Forms-Templates-Signs\Application for Extension-REVISED 1-20-2016.docx