Assisted Living Facility for Elderly Persons License Application

Assisted Living Facility for Elderly Persons License Application

City of Orem Code Section 22-6-9(B) | SLU Code 1281
This application is for the establishment of an Assisted Living Facility for Elderly Persons (SLU Code 1281) within Orem City residential zones. This permitting process ensures that group living arrangements for seniors provide a safe environment while maintaining the essential residential character and harmony of the surrounding neighborhood.

Instructions:

Applicants must demonstrate full compliance with both the Utah State Department of Human Services and Orem City Code. Please complete the certification checklist below and attach all required documentation, including state licenses, safety inspection clearances, and a site plan.

Permit Scope: Any permit issued is nontransferable and applies strictly to the applicant and the specific property listed.

Compliance: The permit remains valid only so long as the facility adheres to all state and local building, safety, health, and zoning requirements.

Revocation: Failure to meet the requirements outlined in this application or the Orem City Code is grounds for immediate termination of the permit and discontinuation of the facility's use.

Important Note: This digital form does not support "Save and Continue." To avoid losing your progress, please ensure you have all required documentation ready before beginning. Incomplete submissions cannot be processed.

Required Documentation Checklist
Please have the following items ready for upload or entry:

Ownership Details: Full contact information for all property and business owners.
A copy of your Utah state license
Staffing Plan: Full names and contact information
Site Plan: A legible diagram of the property identifying:

Any proposed exterior modifications or additions.
The location of a minimum of three (3) designated off-street parking stalls.

2. Applicant & Ownership Disclosure
Legal Name of Applicant (Individual or Entity)

First NameLast Name
Physical Address of Proposed Home

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Managers and Interested Parties (List names, addresses, and phone for all partners/trustees)

Facility Classification (Chapter 22-2-1)
3. Operations & Compliance History (Sec. 18)
Participating Staff Members
Upload a Copy of The Utah State License

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Have You Ever Had a License Revoked?

Mandatory Operational Requirements (Sec. 3-16)
Check each box to certify compliance. Failure to enforce these rules results permit revocation.
Any permit issued pursuant to this Section shall be nontransferable and shall terminate if the structure is devoted to a use other than a residential facility for disabled persons or the structure fails to comply with all building, safety, health, and zoning requirements of the Orem City Code applicable to similar structures. Violation of the requirements listed above shall be grounds for terminating the permit and the owner/operator shall thereafter be required to discontinue the use of the premises as a residential facility for disabled persons.
Please provide a site plan showing the entire property. Include any anticipated changes and indicate where the three (3) 9ft by 18 ft required parking spots will be located. Parking must be paved with materials such as cement or asphalt. Parking is not permitted on graveled areas. No parking spots may restrict access to other parking spots (no tandem parking). Please see the example pdf below.
File Upload

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4. Attestation & Signature
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name
Title (e.g., Manager, Owner)
Email
example@example.com
Should be Empty:

Assisted Living Facility for Elderly Persons License Application

2. Applicant & Ownership Disclosure

Facility Classification (Chapter 22-2-1)

3. Operations & Compliance History (Sec. 18)

Mandatory Operational Requirements (Sec. 3-16)

4. Attestation & Signature