Fillable New Construction Information (Minnesota Department of Revenue)

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New Construction Information (Minnesota Department of Revenue)

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Assisted Living Licensure Application Addendum:
New Construction Information
This is an addendum to the assisted living licensing application form. Use this document if new
construction is identified when submitting the Assisted Living Licensure application.
Submitting Attachments
Applicants must upload attachments to the MDH application portal with their application.
No assisted living services shall be provided until MDH issues a license.
Keep a copy of application and attachment materials. They will not be returned to applicants.
Questions?
EMAIL: health.assistedliving@state.mn.us
New Construction Information
All new license applications with five or fewer residents must meet:
▪ Minn. Stat. sect. 144G.45, subd. 1-3, 6
(https://www.revisor.mn.gov/statutes/cite/144G.45), and
▪ Laws 2020, 7th Spec. Sess., chpt. 1, art. 6, sect. 17
(https://www.revisor.mn.gov/laws/2020/7/Session+Law/Chapter/1/);
and as applicable:
▪ Minn. Stat. sect. 144G.80 (https://www.revisor.mn.gov/statutes/cite/144G.80),
▪ Minn. Stat. sect. 144G.81 (https://www.revisor.mn.gov/statutes/cite/144G.81), and
▪ Laws 2020, 7th Spec. Sess., chpt. 1, art. 6, sect. 22
(https://www.revisor.mn.gov/laws/2020/7/Session+Law/Chapter/1/).
All new license applications with six or more residents must meet:
▪ Minn. Stat. sect. 144G, subd. 1-6 (https://www.revisor.mn.gov/statutes/cite/144G.45), and
▪ Laws 2020, 7th Spec. Sess., chpt. 1, art. 6, sect. 18 to 19
(https://www.revisor.mn.gov/laws/2020/7/Session+Law/Chapter/1/);
and as applicable:
▪ Minn. Stat. sect. 144G.80 (https://www.revisor.mn.gov/statutes/cite/144G.80),
▪ Minn. Stat. sect. 144G.81 (https://www.revisor.mn.gov/statutes/cite/144G.81), and
▪ Laws 2020, 7th Spec. Sess., chpt. 1, art. 6, sect. 22
(https://www.revisor.mn.gov/laws/2020/7/Session+Law/Chapter/1/).
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_________________________________________________________________________
_________________________________________________________________________
ASSISTED LIVING LICENSURE APPLICATION ADDENDUM:
NEW CONSTRUCTION INFORMATION
Did you apply for your building permit before August 1, 2021?
☐ Yes
▪ Attach the complete permit application as an attachment.
▪ Provide the permit application date: ________________________________________
☐ No
Provide the requested information below:
1. Project name: _____________________________________________________________
2. Project narrative: __________________________________________________________
3. Identify which building(s) that is part of the construction project:
4. Architecture/Engineering firm name:___________________________________________
5. Firm contact name: ________________________________________________________
6. Firm contact mailing address:_________________________________________________
7. Firm contact email address: __________________________________________________
8. Firm contact phone number: _________________________________________________
9. Was there a preliminary plan review with MDH?
☐Yes
☐No
If yes, please indicate the appropriate MDH engineer or architect:
10. Indicate project type:
☐ Renovation
☐ Modification
☐ Reconstruction
☐ Change of use or change of occupancy
☐ Addition
11. Number of floors involved in project:___________________________________________
12. Project size in square feet: ___________________________________________________
13. Total square feet of existing building and project (if applicable): _____________________
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ASSISTED LIVING LICENSURE APPLICATION ADDENDUM:
NEW CONSTRUCTION INFORMATION
14. Indicate type of construction per National Fire Protection Association 220, Standard on
Types of Building Construction (https://www.nfpa.org/):
☐ I (442)
☐ I (332)
☐ II (222)
☐ II (111)
☐ II (000)
☐ III (211)
☐ III (200)
☐ IV (2HH)
☐ V (111)
☐ V (000)
For more information contact:
Minnesota Department of Health
Health Regulation Division
PO Box 64900
St. Paul, MN 55164-0900
651-539-3049 or 844-926-1061
health.assistedliving@state.mn.us
www.health.state.mn.us
3/24/2021
To obtain this information in a different format, call: 651-201-4101.
3
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New Construction Information (Minnesota Department of Revenue)

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Completed 28 May 2021

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