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2. Instructions
   Please complete the form with all necessary information. Forms must be filled out completely and accurately to be accepted.
6. CASE INFORMATION:
8. Date*
   Date
9. Case Number *
13. IDENTIFICATION:
15. Applicant/Property Owner's Name*
17. Address of Case/Violation*
19. City*
20. State*
21. Zip*
23. Applicant/Owner's Primary Phone*
27. When reviewing this request, consideration will be given to all pertinent surrounding circumstances including the reasons for the delay, plans for completion, and the amount of progress made to date.
29. Reason(s) for Extension Request*
    Identify reason(s) compliance has not been achieved within the required time frame.
31. Correction(s) made/Plans for Completion*
    Identify what has been corrected and current plans for completion and code compliance.
33. Attach additional information and/or photos, if applicable
35. What is the anticipated completion date?*
37. Please Click the "Submit" button at the bottom of the page. Thank you.
41. Please note:
    If your request is granted and compliance is not achieved by the revised compliance date, or an additional extension has not been granted, fines and/or additional penalties may continue to accrue as stated in the original Rule to Show Cause hearing decision, which can include referring this case to the County Attorney for possible legal action, and/or taking remedial action to resolve the violation(s).
45. This Section is for County Use Only - Please Do Not Fill Out
47. ◊ Extension Granted
48. ◊ Request Denied
49. Extension Period:____________________________
51. Supervisor Signature:_____________________________________ Date:_____________________
53. Building Inspector: _______________________________________ Date:_____________________
55. PLEASE NOTE: Submitting this form constitutes your electronic signature and certifies that you are the owner of the property or its legal or designated representative.
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57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

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