Please complete entire form. 

1

Is this your: 

 *

Is this your:

1st Extension Request

2nd Extension Request

3rd Extension Request

2

Are you the: 

 *

Are you the:

Property Owner

Business Owner

Other

3

Your Information

 *

Your Information

First Name

Last Name

Address

Phone #ext.

Email

4

Address or Code Enforcement Case where violation(s) exist: 

 *

Address or Code Enforcement Case where violation(s) exist:

5

Reason for request: 

 *

Reason for request:

Hardship

Permit or License Pending

Working to Correct Violation(s)

Legal/Civil Action Pending in Court

Other If other, type text here.

6

I acknowledge that I have received: 

 *

I acknowledge that I have received:

Notice of Violation (NOV)

Notice of Pendency (NOP)

Fines associated to my Code Case (if any)

7

Please describe the progress made (if any):

 *

Please describe the progress made (if any):

8

Have you received extentions previously?

 *

Have you received extentions previously?

Yes

No

9

I understand that extensions will not be approved for exigent violations that impact public health and safety. I understand I am requesting additional time to correct the violation notice I previously received. I understand if the request is approved, the violations will be corrected. I understand that I may be subject to additional violations and/or citation or abatement action if the violations are not corrected.

You will receive an email from this office of the approval or denial of your extension request. 

I declare, under penalty and perjury, that the foregoing is true and correct.

 *

I understand that extensions will not be approved for exigent violations that impact public health and safety. I understand I am requesting additional time to correct the violation notice I previously received. I understand if the request is approved, the violations will be corrected. I understand that I may be subject to additional violations and/or citation or abatement action if the violations are not corrected. You will receive an email from this office of the approval or denial of your extension request. I declare, under penalty and perjury, that the foregoing is true and correct.

Yes, I Agree

Full Name

Date

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1