DATE: STATE OF FLORIDA APPLICATION FOR PLAN REVIEW (To initiate project review, all items on both sides

must be complete!)

FACILITY REPORT
FACILITY NAME ADDRESS PHONE CITY

PLEASE UPDATE ALL CHANGES AS REQUIRED LOG NO. (Assigned by OPC) Team (Assigned by OPC) ______________ COUNTY TITLE FAX To be determined PLEASE UPDATE ALL CHANGES AS REQUIRED E-MAIL: Team (Assigned by OPC) ZIP

FACILITY CONTACT PERSON

PROJECT REPORT
______________ PROJECT NAME Facility) CITY _______________

ADDESS OR DESCRIPTIVE LOCATION Same as COUNTY _____________ ZIP ____________ TITLE _________________________________ FAX
(Must be filled in)

PROJECT CONTACT PERSON* Same as above *(For Construction Survey Scheduling) PHONE PROJECT COST ESTIMATE

SPRINKLER REPORT
REQUIRED IS FACILITY COMPLETELY FIRE SPRINKLERED? Yes ( ) Date___________ No (

PLEASE UPDATE ALL CHANGES AS )Not Known ( )

IS FACILITY ON INTERIM FULLY SPRINKLERED CONTRACT? Yes ( ) No (X ) Not Known ( ) If Yes, Exp. IS FACILITY IN FIRE SAFETY EVALUATION SYSTEM (FSES) COMPLIANCE? Yes ( ) No ( ) Not Known/NA (X )

ALL CORRESPONDENCE WILL BE ADDRESSED TO THE FOLLOWING

PLEASE UPDATE ALL CHANGES AS REQUIRED

OWNER
OWNER (COMPANY NAME) OWNER CONTACT PERSON ADDRESS (If different than facility) CITY COUNTY Not known PHONE FAX ZIP 33021 E-MAIL: PLEASE UPDATE ALL CHANGES AS TITLE STATE Florida

BILLING (Must be owner or owners certified representative)

REQUIRED BILLING (COMPANY NAME) . BILLING CONTACT PERSON ADDRESS (If different than facility CITY STATE COUNTY Not Known ZIP 33021 PHONE FAX
AHCA 3500-0011 Nov. 06 Revised: 5/00

TITLE E-MAIL: 1 of 2 (OVER)

(To initiate project review, all items must be complete!) ***PROVIDE A COPY OF THE C.O.N. LETTER OF EXEMPTION OR NON REVIEWABLE AS REQUIRED*** (EXCEPTION: NOT REQUIRED FOR AMBULATORY SURGICAL CENTER) C.O.N. # EXP. DATE_________ SQ. FT (CON)_________EXEMPT #_________NON-REVIEWABLE # _________

ANY CHANGES IN THE DESIGNATED PROJECT PLAYERS MUST BE UPDATED ON THIS FORM AS REQUIRED. NEW FIRMS MUST PROVIDE A REVISED APPLICATION FOR REVIEW AND A LETTER FROM THE OWNER STATING THIS ACCEPTANCE. ALL OTHER STATUTORY REQUIREMENTS FOR ASSUMING ARCHITECTURAL/ENGINEERING REPRESENTATION MUST BE COMPLETED.

THE FOLLOWING FIRMS WILL BE COPIED WITH ALL CORRESPONDENCE PROJECT PLAYER REPORT
ARCH. FIRM Bhide & Hall Architects P.A. PROJECT MGR. Wendell Hall ARCHITECT FOR SIGNING & SEALING Wendell Hall MAILING ADDRESS 1329-C Kingsley Ave. CITY Orange Park STATE FL MECH. ENG. FIRM N/A Engineer MAILING ADDRESS CITY FIRM CERTIFICATION AAC-000569 FLA. REGISTRATION AR -00004951 TELEPHONE NO. 904-264-1919 ZIP CODE 32073 FAX: 904-264-3100 E-MAIL whall@bhide-hall.com FIRM CERTIFICATION PROJECT MGR. FLA. REGISTRATION TELEPHONE NO. ZIP CODE FAX: E-MAIL Not known FIRM CERTIFICATION FLA. REGISTRATION TELEPHONE NO. FAX: FIRM CERTIFICATION FLA. REGISTRATION TELEPHONE NO. ZIP CODE FAX: E-MAIL Not known

STATE

SPRK. ENG. FIRM PROJECT MGR. ENGINEER FOR SIGNING & SEALING MAILING ADDRESS CITY STATE FL ELEC. ENG. FIRM N/A PROJECT MGR. ENGINEER FOR SIGNING & SEALING MAILING ADDRESS Rd CITY STATE

ZIP CODE E-MAIL

ELEC. ENG. FIRM______________________________________________ FIRM CERTIFICATION CA-____________ PROJECT MGR. ______________________________________________ FLA. REGISTRATION PE-_____________ ENGINEER FOR SIGNING & SEALING____________________________ TELEPHONE NO.____________________ MAILING ADDRESS____________________________________________ FAX NO.____________________________ CITY______________________ STATE_______________ ZIP CODE________________ FAX: _________________ E-MAIL __________________________________________ STRUCT. ENG. FIRM FIRM CERTIFICATION PROJECT MGR. ______________________________________________ FLA. REGISTRATION ENGINEER FOR SIGNING & SEALING TELEPHONE NO. MAILING ADDRESS FAX NO. CITY Jacksonville STATE FL ZIP CODE E-MAIL Not known 2 of 2