OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION – www.oshpd.ca.gov/fdd

400 R Street, Suite 200 ~ Sacramento, California 95811 Phone (916) 440-8300 FAX (916) 324-9188
700 N. Alameda Street, Suite 2-500 ~ Los Angeles, California 90012 Phone (213) 897-0166 FAX (213) 897-0168

Application for Amended Construction Documents - Plan Review

A Name of Facility:

OSHPD #:
Address - Street:

Increment #:
(For Designated Increment Projects Only)
City: County: Zip:

Project Name (45 Characters max.): Facility ID #:

B Indicate submission type: Office Use Only

A non-refundable application filing fee of $250.00 will be assessed per submittal for Amended Construction Documents.
OSHPD RECEIPT STAMP
Amended Construction Document # ________________

Note: Documents submitted on or after March 22, 2011 (see instructions)

Addendum AD # ________________________
Instruction Bulletin IB # __________________
IB must be confirmed by change order within 30 days
Change Order CO # _____________________

Note: Documents submitted prior to March 22, 2011 (see instructions)

C Reason for Change:

List of Enclosures:

D Change Order and Amended Construction Documents ONLY

Office Use Only
Total cost of project prior to this change ..................... $ _______________
OSHPD/FDD-Field Review Tracking CPER: Y N
Amount of this change ................................................ $
ACO ___________________________ _______/_______/_______
Add Deduct Architectural A AC D X Refer
Mechanical A AC D X Refer
Revised cost amount to date …………………………..$
Electrical A AC D X Refer
Owner’s Name:
DSE ___________________________ ______/________/_______
Owner’s Signature: Structural A AC D X Refer

FLSO _________________________ _______/_______/_________

This is an estimated cost This is the contract cost
Fire Life Safety A AC D X Refer

E Architect or Engineer in responsible charge of project: Structural Engineer (if applicable):

Signature: Signature:

Firm Name : Firm Name:

License #: _________________________________________________ License #: _________________________________________________

Address: Address:

City: State: Zip: City: State: Zip:

F OSHPD APPROVAL Office Use Only

Signature: Date:

OSH-FD-125 (Rev 01/11) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY Page 1 of 2
 OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT
FACILITIES DEVELOPMENT DIVISION – www.oshpd.ca.gov/fdd
400 R Street, Suite 200 ~ Sacramento, California 95811 Phone (916) 440-8300 FAX (916) 324-9188
700 N. Alameda Street, Suite 2-500 ~ Los Angeles, California 90012 Phone (213) 897-0166 FAX (213) 897-0168

INSTRUCTIONS FOR
Application for Amended Construction Documents - Plan Review
(OSH-FD-125)

Do not write in the shaded Office Use Only areas in this application.

A Enter the name of the facility as it appears on the facility license. Enter the facility street
address, city, county and zip code.

Enter the project name (a 45 character maximum description/scope of the project). The
project name must match the Application for Plan Review and Building Permit.

Enter the Office of Statewide Health Planning and Development (OSHPD) number,
increment number (for designated increment projects only) and facility identification
number. If unknown, refer to the facility’s Application for Plan Review or Building Permit.

B Indicate the submission type by checking the appropriate box and enter sequential
number. The term "Instruction Bulletin" is generally used for any submission, which is not
a change order or an addendum.

All documents submitted to the office before March 22, 2011, may use the Addendum,
Instruction Bulletin and Change Order review process. All documents submitted to the
office on or after March 22, 2011, must use the Amended construction Documents review
process.

Also note, a non-refundable application fee of $250.00 will be assessed for each Amended
Construction Document submittal. Application and documents submitted will not be
processed or reviewed until the filing fees have been paid.

C Reason for change - List or describe the reasons the items above are requested.

List of enclosures - List the enclosures or attachments, which change the contract
documents. Such enclosures must include architect's title block, facility name, and
drawings of changes.

D If this is a change order or Amended Construction Document, complete Section D and

sign by owner; otherwise leave blank. Check the appropriate box indicating if this is an
estimated cost or the actual contract cost.

E The architect or engineer in charge and any other design professional involved in the
change should sign the document in the appropriate signature block, enter the firm name,
the design professional’s license number, firm’s address, city, state and zip code.

F This section is for OSHPD office use only. When returned by OSHPD, staff action taken
will be indicated.

OSH-FD-125 (Rev 01/11) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY Page 2 of 2