HomeMy WebLinkAbout20170689.tiffHEALTH H FACILITIES AND EMERGENCY
MEDICAL SERVICES DIVISION
4300 Cherry Creek Drive South
Denver, CO 80246
Voice: 303-692-2800 Fax: 303-753-6214
www.healthfacilities.info
State Licensure Program
Coloradoment
Pbic Health
of Public Health
and Environment
ZONING DEPARTMENT
Sign off for Local Authorities
Written evidence of compliance with local zoning codes must be obtained prior to issuance of a state license for
operation of a health facility. Contact the city or county department in your area and have the director or designee
sign below. The original signed form must be returned to Health Facilities and Emergency Medical Services Division
(HFEMSD) as part of your application packet.
SECTION A: TO BE COMPLETED BY THE APPLICANT
PURPOSE OF APPLICATION: I ] Initial Application
Secured Unit (ALR or LTC only):
[ ] New Unit [ J Increase from secured beds to secured beds
[ J Increase in Licensed Beds: From
[ I Change of Location: From _
To (Z� Se;
to
I ] Addition / Renovation Scope of Project:
SECTION B: TO BE COMPLETED BY THE APPLICANT
Current Name of Facility:
( C (n (�.L Lc «, cLfi (1 cl
1 -
Facility Type: (Hospital, Nursing Home, etc.) S<,'IsaC' CI. UN( 1 i1. ej St f1C.-.
Address: ?(O Li 5 kA..) Gam.. s-\ ( Po &1l .--)'g.`I) c--)cJ Lkor1 ) Or),
treet City County
No. of Licensed Beds Requested: 074 4'7r 9 vim
Name of Person to Contact: Bk 1, i r 't t tarn Phone: (1 T)) Lj `] t4 . a J F1
SECTION C: TO BE COMPLETED BY THE CITY/COUNTY ZONING DEPARTMENT
Zoning Department having Jurisdiction:
1k
The above -named facility meets the requirements of the local Authority Having Jurisdiction for the occupancy based on
work outlined (If "no" +lease lain ► on a separate attachment.) X] YES [ ] NO
above
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Signature:
Name of Person to Contact:
Address:
C_,V1(.S
Date:
Phone: (970))/OO-353 7Fax: (170) 1/00 - (Ar17
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