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Fire Prevention Request for Extension
{}
W10=
(**) INDICATES DEPT. USE ONLY
*
Registration Number
*
Original Inspection Date
*
Street Location of Building
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Business Name
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Business Address
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Work which has been abated
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Work that remains
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Reason why extension is necessary
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Date work will be completed
PLEASE READ
Pursuant to N.J.A.C. 5:70-2.10(d)2, an application for extension of time shall be deemed to be an admission that the Notice of Violation is factually and procedurally correct and that the violations do or did exist. The following information MUST BE COMPLETED IN ORDER TO BE CONSIDERED, and the information CAN NOT be the same as the Business Address or phone number, UNLESS the owner lives at the address year round.
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Owner's Address
*
Owner's City, State, Zip
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Owner's Phone Number
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Date
**For FPB Use Only
**GRANTED:
FPB Use Only
**The new date by which compliance is ordered is:
FPB Use Only
**DENIED:
FPB Use Only
**The time limit originally imposed remains in effect.
FPB Use Only
Failure to correct violations within the time limits set will result in the imposition of penalties and possibly other enforcement proceedings.
**Date
FPB Use Only
** Inspector Signature
FPB Use Only
**Certification Number
FPB Use Only
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