PERMIT DOCUMENTS �•�=n
CITY OF BOYNTON BEACH
� P= DEVELOPMENT DEPARTMENT I BUILDING DIVISION
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u 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fax 742-6357
TON 9
4.
APPLICATION FOR: ❑ EXTENSION ❑ **REINSTATEMENT
SELECT ONE: ❑ Permit ❑ Permit Application(max of(3)three extensions)
Project Name:
Permit # Li • 3i -72 Job Address: Z y 5 h%q h jOo in 13L v.4 lAsh 11- 5
Contractor of Record: Coo tecx Sic 6 ( (C
Phone: 5c1 _ 'f(.2 -3(.0,3(e Email:`` Qeffy‘;-\5 Q Cci�1 bcEts .(dim • _ .
Mailing Address:3(D2 Le a)ucJ,ac,rn HO()
City 0un kviN eth State: ,c I Zip Code: BIZ
Detailed reason for the extension:
`Ceo4n') SD Z CcAn cc, t -\ c \c &
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 of the extension/reinstatement.
Qualifier/Authorized Agent 2C I I?
Signature bate
SCA 1F (V1,cA2hGt
Printed Name
FOR OFFICIAL USE ONLY
Date of Expiration: Processing Technician Initials:
Application Extension(max of(3)three extensions): Oft$50.00 Ord$75.00 ❑3rtl$100.00
Permit Extension: 01"$50.00 ❑2'575.00 3rd$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 ❑ $75.00 or Permit Fee:
Over 180 days of inactive status ❑...........30% Times 30%
(Whichever is greater) Reinstatement Fee:
&Approved,extended for days ❑ Denied **Additional Ipact Fees may apply
Reviewe by Building Official Date S1
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S:\Development\BUILDING\Forms-Templates-Signs\Application for Extension-REVISED 1-20-2016.docx