Permit Extension Request

Date Submitted

Property Address *

Lot #

Owner First Name *

Owner Last Name *

Owner Mailing Address *

Owner Email *

Owner Phone *

Contractor

Contractor Address

Contractor Email

Contractor Phone

Date of Original Permit Issuance *

Month

Day

Year

Type of Permit *

Description of Circumstances Contributing to Delay of Completion *

Proposed Target Date of Completion *

Month

Day

Year

Please Upload Supporting Documents (if applicable)

Supporting Documents