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Estimated Construction Cost Fee Due see following table on page 2 to calculate Owner or Authorized Representative s Name Type or Print PH-4096 Rev 3/12 Signature Date RDA-0495 When calculating fee round the construction cost up to the nearest one-thousand dollars e.g. 125 101. State of Tennessee Department of Health Health Licensure and Regulation Division of Health Care Facilities 710 Hart Lane 1st Floor Nashville Tennessee 37243 Office Phone 6.

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