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Permit Application Extension Request Form

  1. Permit Extension Request Application
  2. Where applicable, note current contact information where different from issued Permit.
  3. Permittee
  4. Property Owner (Permittee if leave blank)
  5. General Contract (Property Owner If Left Blank)
  6. Electrical Contactor (Property Own if Left Blank)
  7. Plumbing Contractor (Property Owner If Left Blank)
  8. Please respond to the following questions:
  9. Include Year

  10. Include Year

  11. Has authorized work commenced:
  12. Include Year

  13. If yes, and applicable, have building code inspection(s) been conducted “on-schedule”?
  14. Include Year

  15. Check If Item Is Not Available
  16. Certification
  17. I hereby agree to comply with all regulations and codes, which are applicable hereto. I further agree that any misstatement or misrepresentation of facts presented as part of this extension request, or change to proposal without approval of the agencies concerned, shall constitute sufficient grounds for the disapproval or revocation of the subject permit. I hereby affirm that I own the property which is the subject of this application; or that I am the duly designated representative of the property owner, and that I possess the legal authority to make this Affidavit on behalf of myself or the owner for whom I am acting. I do solemnly declare and affirm under the penalties of perjury that the contents of this request are true and correct to the best of my knowledge, information and belief.*
  18. Leave This Blank:

  19. This field is not part of the form submission.