2. Project/Facility Details Type of Facility/License: Hospital Facility Hospital Psychiatric State Outpatient Clinic Birth Center Service Hospital-licensed Child Food Unit Care Center Facility Mobile Hospice Correctional & Chemical Dependency Hospital Surgery Facility Home Alcohol Ambulatory Nursing Services Facility (ESF) Treatment Facility Living Facility Enhanced Residential Assisted (Choose One:) (Choose all that apply:) (Choose contracts, if applicable:) Home ESF—Nursing Mental ALS Living ESF—Assisted EARC/EARC-SD Chemical Family Home ESF—Adult ARC Restraint This project (choose one): a new license a current license Creates amends (adds or renovates a building) This project (choose one): not change bed capacity bed capacity bed capacity does adds reduces Estimated date of construction completion Does this project correct a citation? Yes No If known provide the following: IBC construction type: IBC Occupancy Group: Fire Alarm System Provided? Fire Sprinkler System Provided? Building Permit Jurisdiction (City/County) Yes No Yes No 3. Project Cost Estimate (This is not for flat fees list on page one of this application) New Construction Cost Estimate $ Alterations/Renovations $ Building Conversion total square feet of area= $ Fixed installed equipment $ Equipment Cost Adjustment* $ Construction Cost Estimate Total $ Fee from table () $ Architect Reduction* Less % Previously Licensed Reduction* Less % Adjusted Fee $ *Must be pre-approved by DOH Construction Review Services. Attach copy of approval. 4. Project Description (attach additional pages if necessary) Project Title: Description: DOH 505-046 September 2015 Page 2 of 3
2. Project/Facility Details Type of Facility/License: Hospital Psychiatric Hospital State Facility Hospital-licensed Outpatient Clinic Child Birth Center Food Service Mobile Unit Hospice Care Center Correctional Facility Alcohol & Chemical Dependency Hospital Ambulatory Surgery Facility Nursing Home Enhanced Services Facility (ESF) (Choose One:) ESF—Nursing Home ESF—Assisted Living ESF—Adult Family Home Residential Treatment Facility (Choose all that apply:) Mental Chemical Restraint Assisted Living Facility (Choose contracts, if applicable:) ALS EARC/EARC-SD ARC This project (choose one): Creates a new license amends a current license (adds or renovates a building) This project (choose one): does not change bed capacity adds bed capacity reduces bed capacity Estimated date of construction completion Does this project correct a citation? Yes No If known provide the following: IBC construction type: IBC Occupancy Group: Fire Alarm System Provided? Fire Sprinkler System Provided? Building Permit Jurisdiction (City/County) Yes No Yes No 3. Project Cost Estimate (This is not for flat fees list on page one of this application) New Construction Cost Estimate $ Alterations/Renovations $ Building Conversion total square feet of area= $ Fixed installed equipment $ Equipment Cost Adjustment* $ Construction Cost Estimate Total $ Fee from table () $ Architect Reduction* Less % Previously Licensed Reduction* Less % Adjusted Fee $ *Must be pre-approved by DOH Construction Review Services. Attach copy of approval. 4. Project Description (attach additional pages if necessary) Project Title: Description: DOH 505-046 September 2015 Page 2 of 3
505-047CRSAppPacket.docx