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CORTLAND COUNTY HEALTH DEPARTMENT COUNTY OFFICE BUILDING Lisa Perfetti 60 CENTRAL AVENUE Rm 120 Public Health Director CORTLAND, NEW YORK 13045-2746 Nicole Anjeski, MS, MPH (607) 753-5035 Deputy Public Health Director FAX: (607) 758-5578 Ngozi Mezu-Patel, MD http://www.cortland-co.org/478/Environmental-Health Medical Advisor Division of Environmental Health Michael J. Ryan P.E., Environmental Health Director [EMAIL REDACTED] Plan Review Submission & Fee Checklist Complete the information below and submit with the review fee payment for construction of the regulated facilities listed. Also noted are plan reviews, which require submission of separate forms. Proposed Facility Contact Phone/Fax Proposed (please indicate with a checkmark) Facility Type Requirements Plan Review Fee Hotel / Motel; Children’s Camp; Campground. 1. Engineered plan* See Fee Schedule Public Swimming Pools; Public Beaches. 1. Engineered plan* 2. Engineering Report for Swimming Pool Plan (Form DOH-1308) See Fee Schedule Food Service Facilities: New construction or extensively remodeled. 1. Food Service Plan Review Form See Fee Schedule TOTAL FEE = * NYS licensed professional Engineer required. Please submit plans to this office at the above address. Payment: Please submit a check or Money Order made out to Cortland County Treasurer for the required fee as determined using the above chart. For additional information, please call [PHONE REDACTED]. J:\Environm\WPDATA\-admin-forms-contracts\Forms to complete\plan review request form.doc Based on January 2012 fee amendments Fee Calculation A. Exempt - no fee B. All others A. Exemption Request 1. Is this facility operated by a religious, educational or philanthropic Yes No 2. Is this facility operated by a municipality (city, town, Yes No 3. If the answer to questions 1 or 2 is "yes", you may request exemption from payment of the annual registration fee. Please indicate documentation that will be made available upon inspection request.Incorporation Papers Other (specify) B. Locate category type of your establishment on the list below food service, temporary residence).1. Locate the specific capacity which best reflects your operation. 2. Enter the amount indicated under “Fee Calculation” on the right side of the form. 3. Enter total at bottom of form. 4. Sign and date the fee determination schedule.