PERMIT DOCUMENTS CITY OF BOYNTON BEACH
o f' DEVELOPMENT DEPARTMENT I BUILDING DIVISION
o 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fax 742-6357
TON 0-
-APPLICATION FOR: ❑ EXTENSION V:**REINSTATEMENT
SELECT ONE: ❑ Permit ❑ Permit Application (max of(3) three extensions)
Project Name:
Permit # II On WOO Job Address: 2090 /ib€ Is 44.416
Contractor of Record: elespapd f .g. 1.€24;446"
Phone:( ()7,t4. r1
L4. _ y 2 Email: N//k
Mailing Address:/ 2090 tel lb
City P-9IMILL,M %slat'slatState: . Zip Code: 33Li.3r
Detailed
, -
Detaillled reason for the extension: 60406 I'm gm6 cf �7,u j a
P recT
Otte undersigned, am requesting an extension/reinstatement for the item indicated above. I understand that
submittal of this form does not constitute in itself approval of the extension/reinstatement.
QualfierlAuthorized Agent / - /G • y 2D r'7
'� Signature ate
Printed Name
FOR OFFICIAL USE ONLY
Date of Expiration cc I e..Y/16 Processing Technician Initials:
Application Extension(max of(3)three extensions): 015'$50.00 02nd$75.00 0 3r$100.00
Permit Extension: 01"$50.00 ❑2nd$75.00 03"$100.00 ❑Extension beyond 90 days$250.00(Requires
Building Board of Adjustment&Appeals Approval)
Permit Reinstatement Fee: Total Permit Value: _aC/ol
Under 180 days of inactive status ❑ $75.00 Times 2.3% 4�•
�/
Permit Fee: l 3.`6
Over 180 days of inactive status 7C., $75.00 or* c7
Over 180 days of inactive status ❑ 30% 4 Times 30% O I C --75,0
(Whichever is greater) Reinstatement Fee:
`
Approved,extended for
Vl' days ❑ Denied **Addition I Impact Fees may apply
Reviewed y Building Official Date
S:\Development\BUILDING\Forms-Templates-Signs\Application for Extension-REVISED 1-20-2016.docx