PHONE (757) 385-4211 SUITE 500
FAX (757) 385-5777 VIRGINIA BEACH, VA 23452
TDD (757) 385-4305
Model Plan Modification Request
I, _____________________________, representing _________________________, request a
modification as allowed for under §106.3 of the 2015 Uniform Statewide Building Code (USBC) that
a building permit be issued at the following address _____________________________ under the
provisions and requirements in the 2015 USBC using our model _____________________ plans
that were previously reviewed and approved under the 2012 USBC.
By this request, I agree that the construction in its entirety will comply with all provisions of the
2015 Uniform Statewide Building Code and its referenced codes and standards. I further
acknowledge that should any oversite occur during construction that results in non-compliance with
the 2015 USBC, meeting the minimum provisions of the 2012 USBC and use of 2012 USBC Model
Plans will not be considered as a basis for a modification request to allow for such non-compliance.
I also acknowledge that this request will only be considered for the issuance of a permit on already
approved 2012 USBC plans and will not be considered for the submission and review of new model
plans designed under the 2012 USBC plans on or after 9/4/19.
By submitting this request, I relieve the City of Virginia Beach and its employees from any liability
arising from this request, and I accept all responsibility and liability that may arise from such request.
Print:_______________________________ Sign: ______________________________ Date: _______________
Owner (if different from permittee)
Print:_______________________________ Sign: ______________________________ Date: _______________
Building Official
Request Granted?
Print:_______________________________ Sign: ______________________________ Date: _______________