Free 49453.pdf - Indiana

APPLICATION FOR CONSTRUCTION PERMIT FOR LONG-TERM CARE FACILITIES
State Form 49453 (R2 / 8-06) INDIANA STATE DEPARTMENT OF HEALTH / SANITARY ENGINEERING Approved by State Board of Accounts, 2006

DATE RECEIVED

___________

RECEIPT NUMBER __________ PROJECT NUMBER __________

INSTRUCTIONS:

1. Send check or money order along with plans to: Indiana State Department of Health Attention: Cashier's Office P O Box 7236 Indianapolis, IN 46207-7236 2. Direct questions to 317/233-7177

FAXED COPIES OF APPLICATIONS WILL NOT BE ACCEPTED
1. OWNER _________________________ Name ___________________________ Address _________________________ ________________________________ Phone No. _______________________ 5. The Following Documents are Attached: (CHECK WHERE APPLICABLE) A. Water Supply: Public Private Existing New

B. Plot Plan with Site Utilities: C. Sewage Disposal: Public Private Existing New

2. OWNER'S DESIGNATED AGENT Name ___________________________ Title _____________________________ Address __________________________ _________________________________ Phone No. ________________________

D. Plans and Specifications certified by Architect or Engineer: E. Number of Licensed Beds _____ (1) Comprehensive Care (2) Residential Care F. Fees Required by 410 IAC 6-12-17. (see other side) 6. SIGNATURE Application is hereby made for a Permit to authorize the activities described herein. I certify that I am familiar with the information contained in this application, and to the best of my knowledge and belief such information is true, complete, and accurate. _____________________________________ Printed Name of Person Signing

3. FACILITY (TYPE OF PROJECT) _________________________________ Name ____________________________ Address __________________________ _________________________________ City _____________________________ County _____________ Zip __________

4. ENGINEER/ARCHITECT Name ____________________________ _________________________________ Address __________________________ _________________________________ _________________________________ Phone No. ________________________ License # ________________________ _____________________________________ Date Application Signed (month, day, year) _____________________________________ Title _____________________________________ Signature of Owner or Designated Agent

INSTRUCTIONS FOR COMPLETION OF CONSTRUCTION PERMIT FOR LONG-TERM CARE FACILITIES

1. Owner

Name and address of person, company, firm, municipality, authority, etc., Name, title, address, and phone number of person who is designated to act for owner and who is familiar with the project and can furnish additional information as required. State its name, location, and nearest possible address. Name, title, company, address and phone number of engineer or architect registered in the State of Indiana who certified and sealed the construction plans and specifications. A. Specify the type of water supply serving the subject facility, and whether new or existing. B. Plot plan or plans to scale showing property lines, structures, roads, and site utilities. C. Specify the type of sewage disposal serving the subject facility, and whether new or existing. D. Plans, drawn to scale, shall be prepared, by an individual qualified under applicable laws of the State of Indiana. (See No. 4 above, if applicable). E. Specify the number of licensed beds and indicate the level of licensure below. (1) Comprehensive Care (2) Residential Care F. Fees Required by Rule 410 IAC 6-12-17. Health Facility $150

2. Authorized Agent

3. Name of Facility or Project 4. Name of Engineer/Architect

5. Check the squares indicating name of documents attached to Application. All documents are required except where inapplicable.

6.

SIGNATURE An application submitted by a corporation must be signed by a principal executive officer of at least vice president level or his duly authorized representative, if such a representative is responsible for the overall operation at the facility from which the construction described in the form will originate. In the case of a partnership or a sole proprietorship, the application must be signed by a general partner or the proprietor, respectively.