Application for Permit Extension (1)

Department of Community Development P. O. Box 863 Appomattox, VA 24522 Telephone: (434)352-8183 Fax: (434)352-4214

Application for Permit Extension
Date

MonthDayYear
Date
Contact Name
Phone #
Format: (000) 000-0000.
Permit #
Project Address
I am requesting an extension on the above building permit due to the following reasons
I would like to extend my permit for period of
Applicant Signature
Permits and Inspection Use Only
Extended by
Date Extended

MonthDayYear
Date
Approved by
Date

MonthDayYear
Date
Should be Empty: