Free Free-Standing Community Based Residential Facility (CBRF) Plan Approval Application-F-62496 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62496 (Rev. 04/09)
Reviewer Check Provider

STATE OF WISCONSIN
Page 1 of 3
Transaction No. Check No. Project No.

DQA Office Use Only

FREE-STANDING COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) PLAN APPROVAL APPLICATION

Amount

Plan No.

·

A "free-standing CBRF" is not physically attached to a hospital or a nursing home. If a CBRF is attached to a hospital or nursing home, do not use this form; complete the Plan Approval Application form (F-62333). This form may be reproduced as needed. If this building, following construction of this project, contains more than 50,000 cubic feet in total volume, plans are required to be prepared, signed, sealed, and dated by a Wisconsin registered engineer or architect [COMM 50.07(2)]. A separate plan approval application form and fee must be submitted for each new building, addition to an existing facility and remodeling projects, or for equipment upgrades.

· · ·

SUBMISSION OF MATERIALS AND FEES Failure to adhere to the following submission requirements will delay the plan approval process. Incomplete forms will be returned. Signatures · · · Provide all appropriate signatures. All signatures must be ORIGINAL. Stamped and electronic signatures are not acceptable. Item 10 on page 4 must be signed by the owner or the owner's representative.

Materials to be Submitted 1. Form F-62496 (All sections of the form must be completed.) 2. A minimum of one (1) bound set of plans [Plans shall be drawn to scale per DHS 83.63(2)(c), Wis. Admin. Code.] 3. Three (3) copies of the cover sheet 4. Fee · · Pay only for the plan submitted. Fees may not be paid for future plan reviews. Fees paid for future plans will be refused and the processing of your application will be delayed. Make check payable to: Division of Quality Assurance or DQA.

Submission Locations · ALL MATERIALS MUST BE SUBMITTED TO ONE OF THE TWO ADDRESSES LISTED BELOW. Although plans may be submitted to either address, it is more expedient for plans in the southeastern part of the State (Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties) to be submitted to the Milwaukee Office. Sending materials to other DQA regional offices will delay the plan approval process. MADISON Mailing Address Division of Quality Assurance Plan Review Intake P.O. Box 2969 / 1 West Wilson Street Madison, WI 53701-2969 MILWAUKEE Mailing Address Division of Quality Assurance Plan Review Intake 819 North 6th Street, Room 609B Milwaukee, WI 53203-1606

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DQA CONTACT INFORMATION If you have questions about the completion or use of this form, contact DQA for assistance. Phone: FAX: E-mail: Website: 608-264-7748 608-267-0352 [email protected] http://dhs.wisconsin.gov/rl_dsl/PlanReview/index.htm

F-62496 (Rev. 04/09)

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1. PROJECT INFORMATION
Name ­ Facility (Legal Name) Building Occupancy Chapter(s) and Use Number of Beds County

Physical (Street) Address - Facility

City

State

Zip Code

Project Description (Provide a brief description.)

2. PLAN REVIEW CONTACT PERSON
The contact person indicated below will receive the DHS-assigned reference number and instructions about online verification via e-mail. The reference number will enable the applicant to verify the status of the plan application. A LEGIBLE E-MAIL ADDRESS IS NECESSARY. Name - Contact Person Telephone Number FAX Number E-mail Address

3. LICENSE INFORMATION
Existing License AA New License AA CA AS CS ANA CNA CA A AS CS B ANA CNA C

This building project will change the license from 4. SUBMITTAL REQUEST
A. Type of Project New Building Other (Specify.) Alteration ­ Level: 1 2 3

to

New Addition

Use Change

B. Type of Plan Being Submitted Preliminary Plans (No Fee) Final Plans Revisions to Previously Approved Plans (Designer/Owner Request $100 Fee) Response to DHS Conditional Approval or Withheld Letter (No Fee) C. Type of Review(s) Requested 1. 2. 3. Building HVAC Lighting 6. Fire Alarm System Sprinkler 5. Component Work Separate from Building Structural Component Equipment System Other (Specify.)

4. Fire Protection

5. BUILDING INFORMATION
COMPLETE Sprinkler ­ NFPA PARTIAL Sprinkler ­ NFPA Total No. of Stories Entire Building Footprint Area Sq. Ft. Heat and Smoke Detectors Fire Alarm System Emergency Power Soil Bearing Capacity pfs Presumed Verified

Total Cubic Foot Volume of the Building Upon Completion of the Project less than 50,000 more than 50,000

6. CONSTRUCTION CLASS REQUESTED (existing with waiver only)
1. Fire Resistive Type A 2. Fire Resistive Type B 3. Metal Frame Protected 4. Heavy Timber 5A. Exterior Masonry ­ Protected 5B. Exterior Masonry ­ Unprotected 6. Metal Frame 7. Wood Frame ­ Protected 8. Wood Frame ­ Unprotected

If plans do not show compliance with requested construction class, but can be approved at a lower class, do you wish approval at the lower class? Yes No

F-62496 (Rev. 04/09)

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7. CALCULATION OF FEES PROJECT FEE ESTIMATION Costs must be itemized as indicated. Do not combine costs. Building HVAC Lighting Fire Protection ­ Fire Alarm Fire Protection - Sprinkler Component Work Separate from Building Other (Specify.) Other (Specify.) Total Estimated Project Cost $ $ $ $ $ $ $ $ $ FEE TABLE Total Estimated Project Cost Less than $2,000 $2,000 - $24,999 $25,000 - $99,999 $100,000 - $499,999 $500,000 - $999,999 $1,000,000 - $4,999,999 $5,000,000 and over TOTAL FEES SUBMITTED $ $ $ $ $ Fee 100 300 500 750

$ 1,500 $ 2,500 $ 5,000

8. DESIGNER ATTESTATION AND INFORMATION Provide ORIGINAL signature, signature date, and all contact information for designers of all work indicated in item 4.C.
DESIGN (COMM 61.40) If this building, following construction of this project, contains more than 50,000 cubic feet in total volume, plans are required to be prepared, signed, sealed and dated by a Wisconsin registered engineer or architect (per COMM 61.31). Signature and seals shall be original. I attest that the submitted plans were prepared under my supervision, are accurate, and to the best of my knowledge comply with the applicable codes of the Department of Commerce. Check the type of Designer. SIGNATURE ­ Designer DESIGNER 1 Building HVAC Date Signed Lighting Fire Protection Component Work Other Reg. No. - Designer

Name ­ Designer (Print or type.)

Name ­ Design Firm Telephone Number Mailing Address ­ Street or P.O. Box FAX Number

Name ­ Contact Person

Design Firm Project Number

E-mail Address (MANDATORY. Print clearly or type.) City State Zip Code

Check the type of Designer. SIGNATURE ­ Designer DESIGNER 2

Building

HVAC Date Signed

Lighting

Fire Protection

Component Work

Other Reg. No. ­ Designer

Name ­ Designer (Print or type.)

Name ­ Design Firm Telephone Number Mailing Address ­ Street or P.O. Box FAX Number

Name ­ Contact Person

Design Firm Project Number

E-mail Address (MANDATORY. Print clearly or type.) City State Zip Code

9. OWNER ATTESTATION AND INFORMATION The ORIGINAL signature of the owner (individual or entity) or the owner's authorized representative is required.
(COMM 50.11) I request that plans be reviewed for compliance with DHS 83, Wis. Admin. Code, and the code requirements set forth in Chapters COMM 61 65 of the rules of the Department of Commerce. I recognize that I am responsible for compliance with all code requirements and any conditions of plan approval. If this building exceeds 50,000 cubic feet in total volume, I will retain a supervising professional, as required by COMM 61.31, throughout construction to project completion and the filing of a Compliance Statement by the supervising professional prior to occupancy. SIGNATURE ­ Owner or Authorized Representative Date Signed Name and Title ­ Signatory (Print or type.)

Name ­ Owner / Entity (if different than above) Mailing Address ­ Owner / Entity (Street or P.O. Box) Telephone Number FAX Number

Name and Title ­ Contact Person City E-mail Address State Zip Code