PERMIT DOCUMENTS a'1+o
CITY OH
DEVELOPMENT
OFBOYNTDEPARTMENTNBEACBUILDING DIVISION
. , 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fax 742-6357
6
ETON 0
APPLICATION FOR: ❑ EXTENSION �**REINSTATEMENT
SELECT ONE: 2/Permit ❑ Permit Application(max of(3)three extensions)
Project Name:
Permit # Ko ,DU/ge Job Address: )6,n1 ` b Qa`� 11 nn
Contractor of Record: /C. Cd c (n6V►k i I-fon . clad J ( )
Phone:)'-731 "(16`1 Email:�5�,.,an„trip I colecbn5A-ructen. czyli
Mailing Address: 30(' aiiid Ace 3 #9
CityLica Lthrvk State: 7' Zip Code:
Detailed reason for the extension: t
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I, the undersigned, am requesting an exted to re •tat-• ent for the item indicated above. I understand that
submittal of this form does not constitute i, itsel•a ov. of the extension/reinstatement.
Qualifier/Authorized Agent J 9 -01 - /17
ignatu Date
V , d)e_
.. Printed Name
FOR OFFICIAL USE ONLY /
Date of Expiration: 211 D. I 7-- Processing Technician Initials:
Application Extension(max of(3)three extensions): ❑1"$50.00 ❑2n°$75.00 ❑3rtl$100.00
Permit Extension: ❑1"$50.00 02nd$75.ao ❑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 Times 2.3 %
�� $75.00 . Permit Fee:
Over 180 days of inactive status ❑ $75.00 or
Over 180 days of inactive status El30% Times 30%
(Whichever is greater) Reinstatement Fee:
f Approved,extended for i O days ❑ Denied , **Additional Impact Fees may apply
i'evie ed . . : • •: • 'icial Date
S:\Development\BUILDING\Fo - plates-Signs\Application for Extension-REVISED 1-20-2016.docx