Fillable DS-4100 Application Extension Request for Grading/Right-of-Way and Mapping (The City of San Diego)

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DS-4100 Application Extension Request for Grading/Right-of-Way and Mapping (The City of San Diego)

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This form shall be used to request an application extension for Grading/Right-of-Way Permits or Process One
mapping actions. These applications expire 2 years from the date the application is deemed complete and may
be extended for a period of 180 calendar days per Section 112.0102 of the Municipal Code.
This completed application may be mailed or delivered to the address above.
Attention: Project Processing Section
4. Applicant Name: ___________________________________________________________________________________________________________
Telephone: ________________________________________E-mail Address: _______________________________________________
Address: __________________________________________City: _____________________ State: ________Zip Code:___________
Check one o Property Owner o Authorized Agent of Property Owner o Other Person per M.C. Section 112.0102
Applicant’s Signature: I certify that I have read this application and state that the above information is correct,
and that I am the property owner, authorized agent of the property owner, or other person having a legal right,
interest, or entitlement to the use of the property that is the subject of this application (Municipal Code Section
112.0102).
Signature: __________________________________________________________________________ Date: ________________________
For City Use Only
o Approved
Your request has been granted and the application has been extended to ____________. If a permit has not been
obtained by the date of the newly authorized application extension, the project will be closed. To reapply in the
future, the applicant will be required to submit a new application with required submittal materials, and will be
subject to all applicable fees and regulations in eect on the date the new application is deemed complete.
o Denied
An extension will not be granted on this project for the following reason: ________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
1. Project Address/Location:
2. Project Number:
3. Reason for Extension Request:
Approval Number(s):
Deputy City Engineer Name (Please Print): ________________________________________________________________________
Signature: __________________________________________________________________________ Date: ________________________
PW/PS-149
FORM
DS-4100
OCTOBER 2016
Development Services
1222 First Ave., MS-301
San Diego, CA 92101
(619) 446-5000
Application Extension Request
for Grading/Right-of-Way and
Mapping Projects
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DS-4100 Application Extension Request for GradingRight-of-Way and Mapping (The City of San Diego)

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Completed 16 July 2020

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