BUREAU OF FIRE PREVENTION
PINE HILL FIRE DISTRICT
1109 ERIAL ROAD
PINE HILL,NEW JERSEY 08021
PHONE (856) 784-3994 FAX (856) 784-1195
REGISTRATION NUMBER___________________ ORIGINAL INSPECTION DATE ____________________________
Business Name __________________________________________________________________________________
Business Address __________________________________________________________________________________
Work which has been accomplished ______________________________________________________________________
______________________________________________________________________
Work that remains __________________________________________________________________________________
___________________________________________________________________________________
Reason why extension is necessary _______________________________________________________________________
____________________________________________________________________________________
Date work will be completed ___________________________________________________________________________
Pursuant to N.J.A.C 5:18-2.10(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 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.
Owners HOME ADDRESS ____________________________________________________________________
CITY,STATE,ZIP_____________________________________________________________________
Owners HOME PHONE # ____________________________________________________________________
_______________________________ _______________________________________
Date Signature of owner or agent
FOR DIVISION USE ONLY
Your request for an extension of time to abate violation(s) at the above location is:
( ) GRANTED: The new date by which compliance is ordered is: ________________________________________________
( ) DENIED: The time limit originally imposed remains in effect.
Failure to correct violations within the time limits set will result in the imposition of penalties and possibly other enforcement proceedings.
____________________________________ _____________________________________________
Date Inspectors Signature
REQUEST FOR TIME EXTENSION
