Form Ahca 3500-0011 - State Of Florida Application For Plan Review
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2STATE OF FLORIDA APPLICATION FOR PLAN REVIEW
(To initiate project review, all items on both sides must be complete!)
PLEASE UPDATE ALL CHANGES AS REQUIRED
FACILITY REPORT
LOG NO. (Assigned by OPC)
Team (Assigned by OPC) ______________
FACILITY NAME
__________________
ADDRESS______________________________CITY____________________COUNTY________________ ZIP ___________
FACILITY CONTACT PERSON _____________________________________
TITLE _____________________________
PHONE (____) _______________________
FAX (____) ____________________
E-mail: _______________________
PLEASE UPDATE ALL CHANGES AS REQUIRED
PROJECT REPORT
Team (Assigned by OPC) ______________
PROJECT NAME
ADDRESS OR DESCRIPTIVE LOCATION (If different from Facility)
____________________________________CITY____________________COUNTY________________ ZIP _____________
PROJECT CONTACT PERSON* ___________________________________
TITLE _________________________________
*(For Construction Survey Scheduling)
PHONE (____) ____________________________________
FAX (____) _______________________________
PROJECT COST ESTIMATE
$________________
E-mail______________________________________________
(Must be filled in)
PLEASE UPDATE ALL CHANGES AS REQUIRED
SPRINKLER REPORT
IS FACILITY COMPLETELY FIRE SPRINKLERED? Yes (
)
No (
)
Not Known (
)
ALL CORRESPONDENCE WILL BE ADDRESSED TO THE FOLLOWING
PLEASE UPDATE ALL CHANGES AS REQUIRED
OWNER
OWNER (COMPANY NAME) __________________________________________________________________________________
OWNER CONTACT PERSON ______________________________________________ TITLE _____________________________
ADDRESS (If different than facility) ________________________________________________________________________
CITY_____________________________STATE _______COUNTY________________________ ZIP ____________________
PHONE (____) _____________________
FAX (_____) ___________________E-mail: _______________________________
ALL REVIEW INVOICES WILL BE ADDRESSED TO THE FOLLOWING
PLEASE UPDATE ALL CHANGES AS REQUIRED
BILLING (MUST BE OWNER OR LICENSEE)
BILLING (COMPANY NAME) _____________________________________________________________________________
BILLING CONTACT PERSON ________________________________________________TITLE ___________________________
ADDRESS (If different than facility) ________________________________________________________________________
CITY_____________________________STATE ________COUNTY_______________________ ZIP ____________________
PHONE (_____) ______________________
FAX (_____) ___________________E-mail: ______________________________
page 1 of 2
AHCA 3500-0011 Nov. 06 (Revised April 1, 2009)
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