HomeMy WebLinkAboutplan-check-worksheet-ada Ronald Browder
Director
Additional fee required when
requesting Expedited Plan Check
Expedited Plan Check: Yes ☐
First Response Due: _______________
(7 working days)
PLAN REVIEW WORKSHEET
All fields in the green box are required and must be legible to avoid
delays.
Requestor green portion only
For Office Use:
PR#
AR#
INV#
☐Existing ☐ Change of Ownership ☐ New Facility FA#
Facility Name Identify Pool/Spa
☐Food # of New Hood Exhaust Fans New Dishwasher w/ Hood ☐ Cannabis ☐ Pool ☐ Spa
Requestor/Contact Person:
Email: Phone #:
Business Owner’s Name:
Email: Phone #:
Owner’s Address: City/Zip:
For permitted facilities make sure the establishment name and address match the current permit.
Service Request #: ___________________________________ Census Tract: ____________________
Date First Received: ____________________________
Plan Checker: _______________________________ District EH Specialist: ____________________________
Plan Review Log # Unit: ________________ ____________________________________
Program Element: __________ Fee: $_____________ Payment: $____________ Payment Type: ___________
Hood-Program Element: _________ Fee: $________ Expedited-Program Element: ________ Fee: $_______
Comments:___________________________________________________________________________________
Ronald Browder
Director
1131 Harbor Bay Parkway, Alameda, CA 94502 | Health.AlamedaCountyCA.gov/ACEHD | (510) 567-6700
Activity Codes: O= Office F= Field
When project is completed/terminated, sign here: ______________________________ Date: ____________
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