Extension Request Form

Your Information

Person Requesting Extension *

Email Address *

Daytime Telephone No. *

please include area code with phone number

Inspection Information

Property Address *

Inspector *

Date of Inspection *

Year

Month

Day

Extended Compliance Date Requested *

Year

Month

Day

Item Number(s) in Inspection Report *

Detailed Reason Extension is Needed *

Plan for Compliance *

THECITY
OFBURLINGTON

City Hall
149 Church Street
Burlington, VT 05401
Hours: M-F 8am-4:30pm

(802) 865-7000