Request for Apartment Addition or Deletion and Waivers

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New York State 

Office of Mental Health 

A request form must be submitted before the agency will take any action requiring OMH approval. 

Please send the request form to your local OMH Field Office. 

SECTION A: FACILITY IDENTIFYING INFORMATION 

1. Facility sponsor name: 

2. Program name: 

3. Operating Certificate #: 

4. Requestor's name: Title: 

5. Phone: 

REQUEST FOR APARTMENT ADDITION 

OR DELETION AND WAIVERS (revised 2/2011) 

6. Today's Date: 

Proposed effective date: 

SECTION B: TYPE OF APPROVAL 

(Check the appropriate boxes below and complete the additional indicated sections and subsections). 

1. Initial site for certification. (complete Section C: 1 & 2(b); Section D; and Attachment 1) 

2. New apartment to be added to existing program. (complete Section C: 1 & 2(b); Section D; and Attachment 1) 

3. Existing apartment to be deleted from program. (complete Section C: 1 & 2(a)) 

4. Apartment Capacity increase. (complete Section C: 1 & 2(a); Section D; and Attachment 1) 

5. Apartment Capacity decrease. (complete Section C: 1 & 2(a)) 

6. Transfer apt. from one program to another program within the agency. (complete Sect. C: 1, 2(a) & 3) 

7. Waiver request. (complete Attachment 2) 

8. Other: 

SECTION C: SITE SPECIFIC IDENTIFYING INFORMATION 

1. Apartment capacity: 

current # proposed # 

*If an apartment is to be licensed by OMH for four or more occupants, have the site selection 

requirements of Article 41.34 of the Mental Hygiene Law been met? 

Yes No N/A 

If yes, when was Site Selection Notification sent to municipality? (date): 

(*If there is more than one apartment to be licensed in the same building, the agency needs to check with the local OMH 

Field Office to determine if any action is required under Article 41.34)

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SECTION C: SITE SPECIFIC IDENTIFYING INFORMATION (continued) 

2. (a) Existing apartment address: (#, Street, Apt. #, city, zip) 

(b) New apartment address: (#, Street, Apt. #, city, zip) 

3. Transfer of apartment between licensed apartment programs: 

From: Program Name: 

Apartment OC# 

To: 

Program Name: 

Apartment OC# 

SECTION D: 

(Check all items that apply to your request. Where applicable, be sure to submit all documents that have 

been selected.) 

1. Lease: signed unsigned N/A (not applicable) 

Please note: In accordance with Part 551.10(d) 'If the premises are to be leased but not owned by the applicant, the applicant 

shall identify the owners of the premises and, if the owner is a corporation, include the names of all incorporators and 

directors. The lease or proposed lease shall include the following language: "The landlord acknowledges that rights of reentry 

into the premises set forth in this lease do not confer on the landlord the authority to operate on the premises a facility for the 

mentally disabled, as defined in Article 1 of the Mental Hygiene Law." 

2. Property cost increase? 

Amount of Increase: $ 

Yes 

No 

OMH will inform the agency if any further action is required related to property costs. 

3. Floor plan: Yes No N/A (not applicable) 

If yes, please complete floor plan (Attachment 1).

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SECTION D (continued): 

(Check all items that apply to your request. Where applicable, be sure to submit all documents that have 

been selected.) 

4. Are any bedroom windows designated as escape windows? 

Yes 

No 

Clear opening width (in.): (NYS min. 20", NYC min. 24") 

Clear opening height (in.): 

Clear opening area: 

Height from bottom of window sill to floor: 

(NYS min. 24", NYC min. 30") 

(NYS min. 5.7 sq. ft. & NYC min. 6 sq. ft. 

NYS and NYC allow 5 sq. ft. opening at grade 

level (usually 1st floor)) 

(NYS max. 44" & NYC max. 36") 

Housing built prior to 2000 does not have to meet the 5.7 sq. ft. and the clear openings noted above. However, no matter 

when home was constructed all residences must have, at minimum, a 4 sq. ft. opening with a minimum clear opening of 18” 

wide and 24” high. 

Clear opening measurements are taken when the window is fully opened. This measurement is NOT the overall size of the 

window, but is just the open space created when a window is in an open position. 

Clear opening area in square feet can be calculated by multiplying the width (in inches) by the length (in inches) and then 

dividing by 144. 

“Emergency escape and rescue opening” is defined as an operable window, door or similar device that does not require tools 

to open, providing a means of escape and access for rescue in the event of an emergency. Tools may be required to remove 

guards on windows in high rise buildings where code requires windows to have child safety guards, 

5. The following document is enclosed: 

Certificate of Occupancy 

Documentation in lieu of Certificate of Occupancy

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Attachment 1: Floor Plan for Apartment 

Address: 



Submit a floor plan of the apartment for each level, identify all windows and doors, label each room (living room, kitchen etc.) 

and sleeping areas including room dimensions. Indicate the location of all smoke detectors, carbon monoxide detectors 

and fire extinguishers for every level of the apartment. The floor plan does not have to be drawn to scale. Show two routes 

of escape from every bedroom. Code compliant windows may be used as a second means of escape or rescue. 

Indicate the floor level: 

Basement 1st Floor 2nd Floor 3rd Floor 

Does the building have a sprinkler system? Yes No 

Does the building have an integrated fire alarm system throughout? 

Yes 

Floor #: 

(if above 3rd) 

No

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Attachment 2: Apartment Waiver Request Form 

a) Identify waiver(s) requested: 

Bedroom size 

Actual bedroom width (ft.): 

Actual bedroom length (ft.): 

Actual bedroom area (sq. ft.): 



Number of beds in bedroom: 

(90 sq. ft. for single bedded room and 150 sq. ft. for 2 bedded room are required. 

A waiver of less than 76 sq. ft. for a single or 127 sq. ft. for a double will not be considered.) 

Window opening- (A waiver of less than 4 sq. ft. will not be considered) 

(In NY State 20” wide by 24” high with a minimum of 5.7 sq. ft. or in NY City 24” wide by 30” 

high with a minimum of 6 sq. ft. Both NYS and NYC allow opening of 5 sq. ft. at ground level) 

Bedroom window location: 

(example: 1st floor front bedroom window) 

Number of beds in room (2 beds maximum per bedroom): 

Actual window opening width (in.): 

Actual window opening length (in.): 

(This is the clear space 

made when a window is 

fully opened.) 

Actual window opening area (sq. ft.): 

Support space per resident 

(Includes living room, dining room, kitchen, lounge areas and activity spaces. Does not include 

bedrooms and bathrooms.) 

Number of apartment residents: 

Square feet required: 

(55 sq. ft. per person required) 

Actual square feet available: 

(This measurement is the actual support 

space available, listed in square feet.) 

Other:

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Attachment 2: Apartment Waiver Request Form 

b) Complete the following for all waiver requests: 

1) Identify any compensatory or other existing features of the building which would reduce the 

impact of this waiver: 

(example: building has interconnected alarm, two separate exits directly off apartment hallway) 

2) Describe the resident population of the apartment in terms of medical and supervisory needs: 

(example: has trouble walking, requires minimal supervision) 

3) Justify why completion of renovations required to be compliant with regulations would not be 

practical. (example: window replacement cost of $3,000) 

Estimated renovation costs to meet regulatory requirements: $

Request for Apartment Addition or Deletion and Waivers

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