1

 User information:

User information:

Building Permit/Log Number:

Street Address:

Responsible Party making the request:

Mailing Address (if different than Street Address):

Phone Number:ext.

Email:

2

 Current Permit Status:

Current Permit Status:(Select an Answer) Applied, permit not yet issued Permit issued, construction not started Permit issued, construction started

Explanation of any construction started on the site:

Explanation of Request and intentions to start work:

This form is a request for the Park City Building Official to review the permit for consideration of an extension. Completing this form does not constitute the approval of an extension. Extension approvals shall only be considered for up to 180 days.

3

 Sign and date:

Sign and date:

Applicant Signature:

Date:

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4

FOR OFFICE USE ONLY

FOR OFFICE USE ONLY

Building Official Signature:	Date:
Approved (see conditions below):	Denied:
Conditions/Explanation:

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

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