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INSPECTION C) Water Line Fire S operation CD Date By Date By Y, Date C) CD Pass or Request Inspect. -Type of Insp. Fail Date Date Done By Comments ........... 0 Request. To Revise An Approved Plan ®o� Permit Number: BLD200�_ - Name Parcel Number yz o I Z - a ✓ - 6'C_100_ Phone Number daytime (_6_C f 2 3 Project Address 1�5,5*3 C 5 A Mailing Address _1553 � 5(2 ,,—T Please provide a complete, detailed descriptiW of the proposed revisions to the approved plans: „ w., Aki- Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No Are the approved site plans included? ❑ Yes 0-No Are the revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No If Yes,Has the engineer or architect approved this revision? ❑ Yes ❑ No Is a stamped and signed approval included with this request? ❑ Yes ❑ No (Note:No structural changes to a"designed"Ulan will be approved without the written consent of the engineer and/or architect of record Does the proposed revision modify the footprint or location of the structure? ❑ Yes ❑ No If Yes,Is a revised site plan,.with all new setback dimensions included with this request? ❑ Yes ❑ No Additional Information: Applicant's signature Date: _ 14 le, � Office Use Only Received by. Date Sent Assigned To Approved By Date. B Original Valuation: $ -- 3 -0 Additional Valuation: $ P. Sq.Ft. x$ $ Sq.Ft. x$ $ E.H. Total New Valuation $ Additional Fees: Additional Planning Dept. $ Additional Plan Review $ New Setbacks: Front / Rear / Additional Building Permit $ Side1- / Side2 / Additional Plumbing 8�$ Additional Condition /Comments: Additional Mechanical Additional E.H.Dept. Other $ C Total Amount Due: Amount To Be Paid Up-Front$ . Tah Wu Revised SRG 9=003