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CHFD Request for Time Extension

2. Request for Time Extension Application
   Pursuant to N.J.A.C. 5:70-2.10(d)2, an application for an extension of time shall be deemed to be an admission that the Notice of Violation is factually and procedurally correct and that violation(s) do or did exist.

   Pursuant to N.J.A.C. 5:70-2.10(d)2, an application for an extension of time shall be deemed to be an admission that the Notice of Violation is factually and procedurally correct and that violation(s) do or did exist.

4. Date of Request:*
   Date of Request:

   Date of Request:

5. Business Name:*

6. Occupancy ID:*

8. Address of Property/Business:*

   Include suite or unit number and zip code

10. Violation(s) that have been abated:*

12. Violation(s) which still remain:*

14. Reason for extension:*

15. Date work will be completed:*

17. Name of Business Owner/Agent:*

18. Cell Number:*

19. Email Address:*

21. Acknowledgement :
    You will receive a response from the Inspector indicating if the extension has been granted or denied; if granted, the new date by which compliance is ordered will be provided.

    You will receive a response from the Inspector indicating if the extension has been granted or denied; if granted, the new date by which compliance is ordered will be provided.

22. Compliance:
    Failure to correct violation(s) within the time limits set will result in the imposition of penalties and possibly other enforcement proceedings.

    Failure to correct violation(s) within the time limits set will result in the imposition of penalties and possibly other enforcement proceedings.

24. Administrative Appeal Rights
    Administrative Appeal Rights

Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field