Form Ahca 3500-0011 - State Of Florida Application For Plan Review Page 2
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1
2(To initiate project review, all items must be complete!)
IF REQUIRED BY C.O.N. PROVIDE A COPY OF THE C.O.N. LETTER OF EXEMPTION OR NON REVIEWABLE
(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/FSES CONSULTANT________________________________________ FIRM CERTIFICATION AAC-___________
PROJECT MGR. ______________________________________________
ARCHITECT FOR SIGNING & SEALING___________________________
FLA. REGISTRATION AR -_____________
MAILING ADDRESS____________________________________________
TELEPHONE NO.____________________
CITY______________________
STATE______________
ZIP CODE________________
FAX: _________________
E-MAIL ________________________________________
MECH. ENG. FIRM________________________________________________
FIRM CERTIFICATION CA-____________
PROJECT MGR. ______________________________________________
ENGINEER FOR SIGNING & SEALING____________________________
FLA. REGISTRATION PE-_____________
MAILING ADDRESS____________________________________________
TELEPHONE NO.____________________
CITY______________________
STATE______________
ZIP CODE________________
FAX: _________________
E-MAIL __________________________________________
SPRK. ENG. FIRM________________________________________________
FIRM CERTIFICATION CA-____________
PROJECT MGR. ______________________________________________
ENGINEER FOR SIGNING & SEALING____________________________
FLA. REGISTRATION PE-_____________
MAILING ADDRESS____________________________________________
TELEPHONE NO.____________________
CITY______________________
STATE______________
ZIP CODE________________
FAX: _________________
E-MAIL __________________________________________
ELEC. ENG. FIRM________________________________________________
FIRM CERTIFICATION CA-____________
PROJECT MGR. ______________________________________________
ENGINEER FOR SIGNING & SEALING____________________________
FLA. REGISTRATION PE-_____________
MAILING ADDRESS____________________________________________
TELEPHONE NO.____________________
CITY______________________
STATE_______________
ZIP CODE________________
FAX: _________________
E-MAIL __________________________________________
PLUMB. ENG. FIRM___________________________________________
FIRM CERTIFICATION CA-____________
PROJECT MGR. ______________________________________________
FLA. REGISTRATION PE-_____________
ENGINEER FOR SIGNING & SEALING____________________________
TELEPHONE NO.____________________
MAILING ADDRESS____________________________________________
FAX NO.____________________________
CITY______________________
STATE_______________
ZIP CODE________________
E-MAIL __________________________________________
STRUCT. ENG. FIRM___________________________________________
FIRM CERTIFICATION CA-____________
PROJECT MGR. ______________________________________________
FLA. REGISTRATION PE-_____________
ENGINEER FOR SIGNING & SEALING____________________________
TELEPHONE NO.____________________
MAILING ADDRESS____________________________________________
FAX NO.____________________________
CITY______________________
STATE_______________
ZIP CODE________________
E-MAIL __________________________________________
page 2 of 2
AHCA 3500-0011 Nov. 06 (Revised April 1, 2009)
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