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 #
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

30 Days60 Days90 Days180 Days
Applicant Signature

Clear
Permits and Inspection Use Only
Extended by
Date Extended

MonthDayYear
Date
Approved by
Date

MonthDayYear
Date
Should be Empty: