PERMIT DOCUMENTS C
' CITY BOYNTON BEACH
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DEVELOPFMENT DEPARTMENT I BUILDING DIVISION `�100 East Boynton Beach Boulevard•Boynton Beech,FL 33435•(561)742-6350•Fax 742-6357 t ON O /A )) J M�
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APPLICATION FOR: 111 EXTENSION **REINSTATEMENJ3O,j
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SELECT ONE: Permit ❑ Permit Application (max of(3) three ektensions)
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Project Name:
Permit #
S,VO Job Address: e00/ _ ()Wm DX-
Contractor of Record,jato re CA/C.
Phone:s /—$C2-Bf'f0,0 Email:
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Mailing Address: NOG.• � .�,va�
City //d A/o State: � ta_ Zip Code: 3356 D
Detailed reason for the extension: at/4,44 4F- or d4,hnit , AL
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 extension/reinstatement.
Qualifier/Authorized Agent _ — AS_ ap/7
Date
&anJ t. -:4-1.‘
Printed Name
FOR OFFICIAL USE ONLY �.(
Date of Expiration:Le pla Processing Technician Initials: t I L>
Application Extension(max of(3)three extensions): Oft$50.00 ❑2nd$75.00 ❑310$100.00
Permit Extension: ❑161$50.00 ❑2ntl$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: $d c' Mb
Under 180 days of inactive status C $75.00 Times 2.3% p
Over 180 days of inactive status 1❑ ... $75.00 or Permit Fee: ry SVCS- 00
Over 180 days of inactive status Ly( 30% Times 30%
(Whichever is greater) Reinstatement Fee: 11 1757. SO
E Approved,extended for 3v days ❑ Denied **Additional Impact Fees may apply
I�!i x,(77//7
eview . b ,: Date
S:\Development\BUILDING\For;'-Templates-Signs\Application for Extension-REVISED 1-20-2016.docx
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