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File Size: 34.3 kB
Pages: 1
Date: December 17, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 517 Words, 3,168 Characters
Page Size: Letter (8 1/2" x 11")

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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62457 (Rev. 12/08)


Submission and departmental approval of this form is limited to footings and foundation work and/or the start of demolition work prior to remodeling. This form can not be used for any other purpose. All fields on this form must be completed. Incomplete forms are null and void. A Plan Approval Application form, F-62333, must be submitted with this form. Interim Life Safety Code Plans must be submitted with this form, when applicable. Keep a copy of this completed form for your file. The submission of this form requires an $80.00 fee. Your total fees, calculated on page 5 of the Plan Approval Application (F-62333), should include this $80.00 fee. Submit (1) this completed form, (2) the F-62333 Plan Approval Application, (3) the appropriate fees, and (4) applicable Interim Life Safety Code Plans to the appropriate DQA Office indicated on the Plan Approval Application (F-62333). If you have questions about the use or completion of this form, contact DQA's Plan Review Intake representative or visit the DQA website. E-mail: Phone: (608) 264-7748 FAX: (608) 267-0352 Website:
Date Plans Received By DHS DHS Reference Number

Name - Facility (Legal Name) Physical Address Facility (Street Address) City Project Description (Briefly describe scope of project.) State Zip Code


Prior to approval of the plans and in accordance with COMM 61, HFS 124.29(2) and HFS 132.84(17)(b), we, the undersigned, request to begin (Check one.) Footing and Foundation Work ONLY


Remodeling Project Demolition Work ONLY

We understand that the Department, at this time, may not have completed a detailed review. We have reviewed the specific code requirements for the building or structure and its use, as set forth in COMM 61-65, and HFS 124, 132, or 134, Wis. Admin. Code, and have shown compliance on the drawings where applicable. We agree to make any changes required after the plans have been reviewed and to remove or replace non-code complying parts of the building or structure. We understand that, prior to the start of construction, a Building Permit may be required from the local authorities having jurisdiction in accordance with the laws and ordinances. We understand that if this project is in an unsewered area, a sanitary permit must be obtained prior to the issuance of a local building permit, Chapter 101.12(3)(h), Wis. Stats. We understand that if this project will disturb one or more acres of land, an EROSION CONTROL NOTICE OF INTENT, per COMM 61 and NR 216.47, shall be filed with the Department of Commerce.
Date Signed


SIGNATURE Designer (in INK)

Date Signed

Name and Title - Owner (Print or type.) Name - Company Street Address City State Zip Code

Name Designer (Print or type.) Name Design Firm Street Address City State Zip Code

Department Action

Reviewed By




Not Approved