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Iowa project questionnaire ipq... Iowa Project Questionnaire Date Name of Business: City: Contact Information ? Name: Expansion of Iowa Company Phone: State: Zip: Email: New Location in Iowa 1. Describe the company, its products,

Checklist application form pro... Checklist Required Residential Submittals Application Fee (when required) Completed Application 2 copies of Architectural Plans 2 copies of the current Plat of Survey 2 copies of Civil Engineering

Center of hope project deserve... For office use only: Project DESERVE Application PM / /200 This program provides assistance to current Westar Energy customers. Applications may ONLY be submitted by mail through the United States

Rural task force data sheet ro... RURAL TASK FORCE DATA SHEET ROAD PROJECT Michigan Department of Transportation 1799 (09/11) (To be completed by each county or city for every project submitted to the Task Force) ALL ITEMS MUST BE

Horizon redevelopment project... HORIZON REDEVELOPMENT PROJECT RFP Horizon Project Foundation, Inc. www.charlestonhorizon.com 2012 .version 1.0 Proposals will be received until: November 16, 2012 4:00pm Proposal Title: Horizon Redevelopment

Nc dental screening and varnis... CONSENT Dental Health Fluoride Varnish Program Is Your Child At Risk for Early Childhood Tooth Decay? Fluoride varnish applications prevent tooth decay. To find out if your child is at risk for early

Ac2103 residential application... Residential application for a project information memorandum and/or building consent Section 33 or section 45, Building Act 2004 Date received: Application No: APPLICATION TYPE (tick appropriately)

The pennsylvania verbal behavi... The Pennsylvania Verbal Behavior Project A Beginning Guide to the Intensive Teaching Process of the Verbal Operants 1 Table of Contents Page 1. Introduction........................................................................................................

Builder project completion adv... HBCF HOME BUILDING COMPENSATION FUND Builder Project Completion Advice (All fields are mandatory) This form is not to be used in the case of contract disputes or termination before practical completion.

Public works affidavit califor... PUBLIC WORKS AFFIDAVIT California Labor Code 1775 b 4 The undersigned Contractor/Subcontractor has complied with the provisions of the has paid all employees the specified general prevailing rate of per diem wages to its employees and any amounts due pursuant to 1813 on the public project Project Name C0404 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Idph project submission form h... Project Submission Form for Hospitals Project identifying information All sections of this form must be completed. Altered forms will not be accepted IDPH Number Facility name Street address City IL ZIP code Project name IF THIS PROJECT CHANGES THE FACILITY S LICENSED BED COUNT BY ADDING OR REDUCING BEDS IT WILL BE NECESSARY TO CONTACT THE HEALTH FACILITIES SERVICES AND REVIEW BOARD. Is this a phased occupancy project Yes No If yes attach an occupancy schedule describing the rooms to be occupied in each phase with a small scale graphic plan Type of project new/replace facility addition to existing facility PPS rehab unit Type of submission renovation/update to existing facility PPS psychiatric unit Safety Net/Community hospital grant design development drawings first stage construction/working drawings second stage Certificate of Need Submit a copy of the approved certificate of need CON. A review by the Department WILL NOT begin until a CON or appropriate documentation is received* Written documentation from the Health Services and Review Board may be requested indicating a CON is not required* CON project number Date approved Functional program narrative Provide a functional program narrative for the project that describes the purpose of the project departmental relationships space requirements and other basic information relating to fulfillment of the facility s objectives. The functional program shall include a description of those services necessary for the complete operation of the facility. Attach additional sheets if needed* Systems program narrative Provide a systems program narrative describing all special systems including but not limited to fire alarm nurses call special locking devices security packages electrical plumbing HVAC medical gas and fire protection* Form Number 443086-rev021914 Page 1 of 5 Estimated project cost 1. Site preparation costs 2. Demolition costs 3. Construction contracts including cost of materials 4. Change orders Subtotal - lines 1 thru 4 6. Fixed capital equipment Add lines 5 and 6 If the fixed capital equipment is not more than 51 percent of the total cost then use line 7 for the plan review fee calculation below. 8. If line 6 is 51 percent more than line 7 then multiply line 6 by. 20 Place the total adjusted estimated project cost in the appropriate estimated project cost category listed below. diagnostic equipment MRI scanners X-ray equipment etc. Equipment which is part of the building such as AHU boilers chillers lights fire alarm panels and all related components are to be included in the construction costs. Plan review fee calculation The plan review fee is due and payable upon submission of this form along with the drawings and required information* Using the figures in line 7 or line 9 whichever is applicable calculate the plan review fee. Fee as listed below Less than 500 000 No fee 500 000 - 999 999 Project cost x. 0096 or 6 000 whichever is greater x. 0022 x. 0011 Greater than 5 000 000 10. Plan review fee to be submitted 11. Is the facility a disproportionate share hospital 13.

Pmp certification application... PMP Certification Application PAGE 1 OF 6? ? YOUR INFORMATION Tips for completing this form: Hand-write your information clearly in blue or black ink onto a printed form and submit it by postal mail.

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