The PH-3477 form serves as a critical document within the Tennessee Department of Health's Bureau of Licensure and Regulation, specifically within the Division of Health Care Facilities, Engineering Section. Located on Hart Lane in Nashville, this division requires the form for the submittal of plans pertaining to new construction, renovation, or addition projects related to health care facilities. The form captures detailed information about the project, including its description, type, name, address, and the contact details of the owner and the primary contact person. It extends to request details about the project's architect or engineer, the sprinkler contractor, and various other contractors involved. This meticulous approach ensures clear communication between project managers and the regulating body, streamlining the review process. Additionally, the form outlines requirements for construction start and completion dates, occupancy and construction type in compliance with safety codes, building area measurements, and whether a Certificate of Need (C.O.N.) or a licensing application fee is necessary. The instructions for calculating associated fees based on the estimated construction cost highlight the department's thorough review process. The completion and submission of this form are crucial for compliance and safety standards, signifying the extensive regulatory framework in place to oversee health care facility constructions or modifications in Tennessee.
| Question | Answer |
|---|---|
| Form Name | Form Ph 3477 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | G6011115, Sprinklered, 1999, Licensure |
State of Tennessee
Department of Health
Bureau of Licensure and Regulation
Division of Health Care Facilities, Engineering Section
710Hart Lane, 1st Floor Nashville, Tennessee 37243 Office Phone:
PLANS REVIEW SUBMITTAL FORM
(For Office Use Only)
State Project #
Description of Project _________________________________________________________________________________________
Type of Project (check one) New Construction [ ] Renovation [ ] Addition [ ]
Project Name ________________________________________________________________________________________________
Street Address ______________________________________________________________________________________________
City _________________________________________Zip Code ________________________County _______________________
Project Owner ______________________________________________________________Telephone ( |
) _________________ |
Contact Person ______________________________________________________________ Fax ( |
) _____________________ |
Mailing Address _________________________________________________________________________________________
City ________________________________________State ________________________ Zip Code ______________________
Project Architect/Engineer ____________________________________________________Telephone ( |
) ________________ |
A/E Firm _____________________________________________________________________ Fax ( |
) ____________________ |
Contact Person _____________________________________________________________________________________________
Mailing Address __________________________________________________________________________________________
City ______________________________________State ___________________________Zip Code _______________________
Sprinkler Contractor _________________________________________________________Telephone ( |
) _________________ |
Contact Person _______________________________________________________________ Fax ( |
) ____________________ |
Mailing Address ___________________________________________________________________________________________
City _____________________________________State ____________________________Zip Code _______________________
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Construction start (approximate date) ______/______/______ Construction completion (estimated date) ________/_______/______
(month) (day) (year)(month) (day) (year)
Occupancy Type (as defined by NFPA Life Safety Code 101, 2003 edition) ________________________________________________
Construction Type (as defined by Standard Building Code, 1999 edition) |
I |
II |
III |
IV |
V |
VI |
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(circle one) |
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One Hour Protected? YES NO Sprinklered? |
YES |
NO |
Height ________ ft. |
Number of Stories ___________ |
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(circle one) |
(circle one) |
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Building Area (outside wall to outside wall as defined by Standard Building Code, Section 202, 1999 edition) |
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New Construction ___________ sq. ft. per largest floor |
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Existing Construction ____________sq. ft. per largest floor |
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Total (all floors) _____________ sq. ft. |
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Total (all floors) ________________ sq. ft. |
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Existing Building Construction Type___________________ |
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Certificate of Need (C.O.N.)? YES NO (If yes, attach copy of Certificate of Need) C.O.N. Expiration Date _____/_____/______
(circle one) |
(month) (day) (year) |
Licensing Application and Fee Required? |
YES NO (If fee is required, it must be paid prior to review) |
|
(circle one) |
Ship Approved Drawings to ______________________________________________________________________________________
FED/EX # ________________________________ UPS # _________________________________ Other ________________________
In accordance with Rule
(NOTE: The State reserves the right to request verification of costs.)
Estimated Construction Cost: $____________________ |
Fee Due (see following table on page 2 to calculate): $________________ |
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___________________________________________________ |
_________________________________________________________ |
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Owner or Authorized Representative’s Name (Type or Print) |
Signature |
Date |
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When calculating fee, round the construction cost up to the nearest
ESTIMATED CONSTRUCTION |
COST TO CALCULATE FEE |
$1.00 TO $50,000.00 |
$260.00 minimum |
$50,001.00 to $100,000.00 |
$260.00 for the first $50,000.00, |
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plus $3.00 for each additional |
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thousand or fraction thereof, to |
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and including $100,000.00 |
$100,001.00 to $500,000.00 |
$410.00 for the first $100,000.00 |
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plus $2.00 for each additional |
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thousand or fraction thereof, to |
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and including $500,000.00 |
$500,001.00 and up |
$1,210.00 for the first $500,000.00, |
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plus $1.50 for each additional |
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thousand or fraction thereof, with |
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a maximum of $20,000.00 |
CM/G6011115/ENG |
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