Form Osh Fd 121 – Fill Out and Use This PDF

The OSH-FD-121 form is a comprehensive document used by the Office of Statewide Health Planning and Development Facilities Development Division in California. It serves as a project application for various types of construction and development within healthcare facilities, including seismic retrofit programs, building permits, and compliance plan reviews. To ensure your healthcare facility project adheres to state regulations, complete and submit the OSH-FD-121 form by clicking the button below.

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Form Osh Fd 121 PDF Details

Navigating the complexities of healthcare facility development in California requires a clear understanding of various forms and procedures, one of which is the Office of Statewide Health Planning and Development Facilities Development Division's OSH-FD-121 form. This comprehensive document serves as a project application form, designed specifically for entities looking to undertake construction projects within healthcare facilities that fall under the jurisdiction of the Office of Statewide Health Planning and Development (OSHPD). It caters to a wide array of project types, including seismic retrofit programs, new project applications, compliance plan reviews, and applications for building permits, among others. The form additionally accommodates requests for upgrades and the removal of acute care services, demonstrating its versatility in addressing the diverse needs of healthcare facility development. Important sections of the form inquire about project specifics such as project and increment numbers, facility information, types of facility involved, contact details of the legal owner or administrator, and designated facility representatives. Further, it outlines the professionals responsible for the project, encompassing disciplines like architecture, civil, electrical, and structural, to ensure comprehensive project oversight. The OSH-FD-121 form also delves into the financial aspects of proposed projects, requesting detailed cost estimates while providing space for including necessary enclosures that support the application. This meticulous approach underscores the state's commitment to maintaining high standards in healthcare facility development and ensures that every aspect of proposed projects is thoroughly evaluated to comply with California's health and safety regulations.

Question	Answer
Form Name	Form Osh Fd 121
Form Length	11 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 45 sec
Other names	Submittal, PCA, CALIFORNIA, SPC

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OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT FACILITIES DEVELOPMENT DIVISION

RECEIVED

				OFFICE USE ONLY
Project Application			Project #	Increment #
Project
Type
 Alternate Method of Compliance  Application for Seismic Extension (select one)				 Seismic Retrofit Program (select one)
 Annual Building Permit		 NPC		 Application for Seismic Evaluation Report
 Application for Building Permit		 SPC		 Compliance Plan Review
 Application for Building Permit		 Incremental (select one)		 Request for NPC or SPC Upgrade
 Application for New Project		 Incremental (select one)		 Request for NPC or SPC Upgrade
 Application for New Project		 Increment		 Removal of Acute Care Services (select one)
		 Increment		 Removal of Acute Care Services (select one)
		 Master		 OSHPD Jurisdiction Requested
		 Phase Segment		 Local Jurisdiction Requested
Facility
Project #
Facility #		Facility Name
OSHPD Building #	BLD -	Building Name
OSHPD Building #	BLD -	Building Name
OSHPD Building #	BLD -	Building Name

Type of Facility  Acute Psychiatric Hospital

 General Acute Care Hospital  Skilled Nursing or Intermediate Care Facility

 Correctional Treatment Center

 Licensed Clinic

Address

Street Address

Address Line 2

City

County

State CA

Zip Code

Phone

Contact

 Primary

Type

Legal Owner / Administrator (Required for all applications)

First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

Signature

Date

Notes

 Primary

Type

Authorized Agent (Authorization must be attached)

First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

Signature

Date

Notes

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Page 1 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

OFFICE USE ONLY

Project Application

Project #

Increment #

Contact

 Primary

Type

Facility Representative

First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

Notes

 Primary

Type

 Accounting

 Applicant

 Billing

(duplicate page if needed)

First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

Notes

Record Detail

Record/Project Name

Detailed Description

Application Specific Information – Plan Review

Submittal Type

 AB 2632

 Examination

 Phased Review Requested

Collaborative Phased Review Requested

 Final

 Preliminary

(Under Development)

Collaborative Review Requested

 GeoTech Only

 SB 1838

(Under Development)

Managed Project Requested

 Yes  No

Final Following Preliminary Submitted Date

(Presubmittal meeting – For projects $20 Million and above)

Kind of Project

 Addition

 Maintenance

 New Building

 Remodel/Alteration

Total Beds Before Construction

Total Beds After Construction

Square Footage of Project

Project includes Primary Gravity and/or Lateral Load Elements/Systems

 Yes  No

Seismic Compliance Construction Project  Yes  No

Use Annual Building Permit  Yes  No

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Page 2 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

OFFICE USE ONLY

Project Application

Project #

Increment #

Professionals

 Responsible Primary

Type

Architect

License/Certificate Number

First Name

M.I.

Last Name

Alternate Contact First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

 Responsible Primary

Type

Civil

License/Certificate Number

First Name

M.I.

Last Name

Alternate Contact First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

 Responsible Primary

Type

Contractor

License/Certificate Number

First Name

M.I.

Last Name

Alternate Contact First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

 Responsible Primary

Type

Electrical

License/Certificate Number

First Name

M.I.

Last Name

Alternate Contact First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Page 3 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

OFFICE USE ONLY

Project Application

Project #

Increment #

Professionals

 Responsible Primary

Type

GeoTechnical

License/Certificate Number

First Name

M.I.

Last Name

Alternate Contact First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

 Responsible Primary

Type

Mechanical

License/Certificate Number

First Name

M.I.

Last Name

Alternate Contact First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

 Responsible Primary

Type

Structural

License/Certificate Number

First Name

M.I.

Last Name

Alternate Contact First Name

M.I.

Last Name

Organization Name

Street Address

Address Line 2

City

State

Zip Code

Phone

Phone 2

Fax

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Page 4 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

					OFFICE USE ONLY
Project Application			Project #		Increment #
Costs
Cost Type	 Contract			Construction Costs
	 Estimated	(excluding fixed equipment, imaging equipment,
		design fees, inspection fees, and off-site improvements)			$
		Note: For SB 1838 projects, this amount must not exceed $50,000			$
		Fixed Equipment Costs			$
		(sterilizers, chillers, boilers, etc., excluding installation)			$
		Cost of Imaging Equipment			$
		(X-ray, MRI, CT Scan, etc., excluding installation cost)			$

Note: See Instructions for Fee Information

Reason

Enclosures

Number	Enclosure Type	Number of	Enclosure Type
of Copies	Enclosure Type	Copies	Enclosure Type
	Application for New Project		Plans
	Building Permit Form		Project Schedule
	Certificate of Insurance		Site Data Reports
	Contract Information		Specifications
	Demolition Plans		Structural Calculations
	Design Program		Testing, Inspection and Observation Program (TIO)
	Equipment Anchorage Calculations		Transmittal Letter (Section 7-131)
	Geotechnical Reports (for Buildings and Additions)		Verification of Conformance to Local Codes
	Inspector Qualification Form		Other _____________________________________
	Letter of Authorization

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Page 5 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

			OFFICE USE ONLY
Project Application		Project #	Increment #
Seismic Compliance
Building #	Building Name

Deficiencies Mitigated

SPC From

 1

 2

 3

 4

 5

SPC To

 1

 2

 3

 4

 5

SPC

 Full

 Partial

NPC From

 1

 2

 3

 4

 5

NPC To

 1

 2

 3

 4

 5

NPC

 Full

 Partial

Building #

Building Name

Deficiencies Mitigated

SPC From

 1

 2

 3

 4

 5

SPC To

 1

 2

 3

 4

 5

SPC

 Full

 Partial

NPC From

 1

 2

 3

 4

 5

NPC To

 1

 2

 3

 4

 5

NPC

 Full

 Partial

Building #

Building Name

Deficiencies Mitigated

SPC From

 1

 2

 3

 4

 5

SPC To

 1

 2

 3

 4

 5

SPC

 Full

 Partial

NPC From

 1

 2

 3

 4

 5

NPC To

 1

 2

 3

 4

 5

NPC

 Full

 Partial

Building #

Building Name

Deficiencies Mitigated

SPC From

 1

 2

 3

 4

 5

SPC To

 1

 2

 3

 4

 5

SPC

 Full

 Partial

NPC From

 1

 2

 3

 4

 5

NPC To

 1

 2

 3

 4

 5

NPC

 Full

 Partial

Building #

Building Name

Deficiencies Mitigated

SPC From

 1

 2

 3

 4

 5

SPC To

 1

 2

 3

 4

 5

SPC

 Full

 Partial

NPC From

 1

 2

 3

 4

 5

NPC To

 1

 2

 3

 4

 5

NPC

 Full

 Partial

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Page 6 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

				OFFICE USE ONLY
Project Application			Project #	Increment #
Phase Master Plan
Phase 1 – Conceptual/Criteria
Segment	1A	Segment Description		Est. Submittal Date


Segment	1B	Segment Description		Est. Submittal Date


Segment	1C	Segment Description		Est. Submittal Date

Phase 2 – Detailed Design

Segment

Segment Description

Segment

Segment Description

Segment

Segment Description

Phase 3 – Pre-Implementation

Segment

Segment Description

Segment

Segment Description

Segment

Segment Description

Est. Submittal Date

Phase 4 – Implementation (Final Review)

Segment

Segment Description

Est. Submittal Date

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Page 7 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

				OFFICE USE ONLY
Project Application			Project #	Increment #
Deferred Items
	Applicant
Discipline	Tracking Number	Description of Deferred Item

Architectural

Demolition/Site

Electrical

Engineering Geologic

Fire and Life Safety

Geotechnical

Mechanical

Secondary Structural

Structural

Supplemental Ground Response

Structural Analysis Software

Structural Analysis Software Used (check all that apply)

 Enercalc	 LPile	 Perform 3D	 RISA 3D
 ETABS	 PCA Column	 RAM Structural System	 SAFE
 LGBeamer	 PCA Slab	 Retain Pro	 SAP 2000
			 Other _______________


For construction in Northern California,,		For construction in Southern California, submit to:
Seismic Review and Clinics, submit to:		Office of Statewide Health Planning and Development
Office of Statewide Health Planning and Development
		Facilities Development Division
Facilities Development Division		700 North Alameda Street, Suite 2-500
400 R Street, Suite 200		Los Angeles, CA 90012
Sacramento, CA 95811		(213) 897-0166 phone
(916) 440-8300 phone		(213) 897-0168 fax
(916) 324-9188 fax

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Page 8 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

INSTRUCTIONS FOR APPLICATION FOR NEW PROJECT (OSH-FD-121)

This form is required for all application submittals and is to be accompanied by all required project specific forms.

Note: If licensure by the California Department of Public Health is not required by your facility, review by OSHPD is not required; therefore this application is not required. Contact the local jurisdiction for submittal requirements.

Project

The selected box indicates the type of application for submittal.

Facility

•Enter the Office of Statewide Health Planning and Development (OSHPD) facility identification number. If this application is for construction of a new facility and an OSHPD facility identification number has not yet been assigned, contact the office for this number.

•Enter the name of the facility as it appears on the facility license.

•Enter the building number and name which the requested work is to be performed.

•Check the box for the type of facility as it is licensed.

Address

•Enter the facility street address, city, county, zip code and phone number.

Contact

Note: Copies of all correspondence will be sent to the facility representative. If a facility representative address is not entered, copies of all correspondence will be sent to the facility address as indicated on the license, to the attention of Facility Administrator.

•Enter the contact information for the legal owner / administrator (this information is required for all applications) , authorized agent, and facility representative. Include the name, organization name, street address, city, state, zip code, phone number, fax number and email address. Information for accounting, applicant, and billing is optional. If additional space is needed, duplicate this page.

•A signature and date are required for the legal and authorized agent. If an authorized agent is signing on behalf of the legal owner /administrator, the authorization must be attached.

•Indicate who will be the primary contact for this project.

•Provide any additional information in the notes area, as necessary.

Record Detail

•Enter the record/project name.

•Enter a detailed description of the work to be performed.

Application Specific Information – Plan Review

•Indicate the type of submittal for this project by placing a check in the appropriate box. If selecting a collaborative review, phased review or collaborative phased review, complete the Phase Master Plan section.

•Indicate if a managed project review is requested. Refer to Title 24, California Administrative Code, Section 7-111, Definitions.

•If preliminary or final is checked as the type of submittal, enter the date of the presubmittal meeting (for projects with an estimated construction cost greater of $20 million and above).

•Check the box for the kind of project. Refer to Title 24, California Administrative Code, Section 7-111, Definitions.

•Enter the total bed count before construction and after construction. If the bed count is not being affected by this project, this information is not required.

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Instruction Page 1 of 3

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

INSTRUCTIONS FOR APPLICATION FOR NEW PROJECT (continued)

(OSH-FD-121)

•Enter the square footage of the project. For new building construction and additions, the square footage shall be the total building area as defined in the California Building Code, Section 502.1 for AREA, BUILDING for all floors, including basements, penthouses, canopies, etc. For remodels, the square footage shall be the total building area included within the scope of the work. For example, if a unit is being converted from Acute Care to Skilled Nursing, the square footage will include the total building area of the unit, not just the area of the rooms or spaces in which actual construction work occurs. Equipment replacements shall be considered remodels and the square footage shall be the building area within the room, space, or equipment pad, as applicable to accommodate the replacement. For example, if you are replacing a CT Scanner, the square footage is the area of the CT Scan Room. If a chiller is being added or replaced, the square footage would be the area of the chiller pad and not of the entire central plant. If additional related work is included in the scope of work, include the building area within the scope boundaries. The square footage for maintenance work shall be zero.

•Indicate if the project includes primary gravity and/or lateral load elements/systems.

•Indicate if the project is a Seismic Compliance Construction Project. If yes, the Seismic Compliance section must be completed.

•Indicate if the project is billed to an Annual Permit.

Professionals

Note: Plans returned for correction or stamping will be sent to the responsible primary, as indicated in this section.

•Enter the contact information for the professionals responsible for this project. Include the license/certificate number, name, alternate contact, organization name, street address, city, state, zip code, phone number, fax number and email address.

•Indicate the discipline in responsible charge of the project by selecting Responsible Primary. If plans need to be returned, they will be sent to this individual. A licensed specialty contractor can only be responsible on projects pursuant to Title 24, California Administrative Code, Section 7-115 (c).

•If additional space is necessary, duplicate the page.

Costs

•Select whether the costs indicated are contract or estimated.

•Enter the construction cost of the project excluding fixed equipment to be permanently attached (electrically, mechanically or structurally) to the building, imaging equipment, design fees, inspection fees, and off-site improvements. For SB 1838 projects, this amount must not exceed $50,000.

•Enter the cost or value of fixed equipment (items that are permanently affixed to the building or permanently connected to a service distribution system that is designed and installed for the specific use of the equipment), excluding installation costs.

•Enter the cost or value of imaging equipment (X-ray, MRI, CT Scan, etc.), excluding installation cost.

Fee Information:

Acute Care Hospital fees shall be 1.64% of the contract/estimated construction cost, including fixed equipment. Imaging equipment shall be 0.164% of the contract/estimated cost or value.

Skilled Nursing Facility fees shall be 1.5% of the contract/estimated construction cost, including fixed equipment.

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Instruction Page 2 of 3

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION

INSTRUCTIONS FOR APPLICATION FOR NEW PROJECT (continued)

(OSH-FD-121)

Enclosures

•Indicate the number of copies enclosed in the space provided, next to the applicable enclosure type.

Note: Submit two (2) sets of plans, specifications, structural calculations, and equipment anchorage calculations.

Submit three (3) sets of geotechnical reports for projects involving new facilities and additions to existing facilities.

Submit two (2) copies of the Testing, Inspection, and Observation Program (TIO).

Submit one (1) copy of the design program (optional).

Submit one (1) copy of the required verification of conformance to local code.

Seismic Compliance

This section must be completed when submitting Seismic Compliance Construction Projects.

•Provide the following information for each building in this project: O Building number and name

O Deficiencies mitigated by this project

O Enter the Structural Performance Category (SPC) before and after construction, and if this is full or partial compliance.

O Enter the Nonstructural Performance Category (NPC) before and after construction, and if this is full or partial compliance.

Note: Full Compliance should only be chosen if this Seismic Compliance Construction Project meets all requirements for SPC/NPC compliance for the listed building as designated in the Seismic Compliance section.

Phase Master Plan

This section must be completed when submitting Phased and Collaborative review projects.

Deferred Items

Note: Where a portion of the design cannot be fully detailed on the approved construction documents because of variations in product design and manufacture, the approval of the construction documents for such portion may be deferred until the material suppliers are selected. OSHPD has sole discretion as to the portions of the design that may be deferred. All deferred items allowed by OSHPD must be clearly described on the construction documents. Deferred submittals must comply with Title 24, California Administrative Code Section 7-126.

Structural Analysis Software

•Indicate the type of structural design software used in the preparation of the design.

Note: If your designs were not prepared using software listed in this area, please be advised that plan review may be delayed while OSHPD develops a work-around, or purchases the software indicated.

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-121 (Rev10/26/12)	Instruction Page 3 of 3

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