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INTERAGENCY REQUEST FOR INSPECTION ' � TURN TO: Division of Licensing <br /> •Ii MN Dept. Human Services <br /> 0 71, /S' "`'" 0f D 444 Lafayette Road <br /> St. Paul, MN 55155 <br /> TO: � Gn� , [ ] State/Local Health Inspector <br /> 6 6 !JUL 1o • Local Building Code Inspector <br /> v ) State/Local Fire Inspector <br /> i P7-/7 5 53-:z 3 <br /> FROM: e_)-/ . 4,-a -v"`1-ce-,20 <br /> -63yLicensing Consultant DATE: //,&-//,,S--- <br /> Prior <br /> Prior to issuing a license, verification is required that a facility is in compliance with <br /> appropriate state or local codes for health, building and fire. Please complete the <br /> appropriate section and return to the Licensing Division with any orders attached. A copy <br /> of orders should be provided to the program. /� <br /> Name of Facility: Proposed Use: Ge ,� <br /> Name of Program: 1,U .&-7-L erL. Phone: y7 3 -7 Lis-- <br /> Address:8"SO WA- a--", oiL L J Pmt 0217SS3 7' / <br /> Street C' ' Zip <br /> Area to be used: Numbers and Age Ranges of Participants: Facility Plans to <br /> Basement [ 6 wks. to 16 mos. serve handicapped: <br /> First [ 16 mos. to 2 1/2 yrs. 7 Yes [ ] <br /> Second [ ] 2 1/2 yrs. to 6 yrs. K No [ <br /> Other [ ] 6 yrs. to 12 yrs. <br /> Specify: over 12 yrs. <br /> 3S <br /> HEALTH REQUEST: [ ] Licensed [ ] Not Licensed [ ] Application left or mailed <br /> [ ] No orders necessary at time of inspection [ ] Major orders issued <br /> ( ] Minor orders issued [ ] Major revisions needed before license can be issued <br /> Signature: Date: Comments: Reverse side <br /> BUILDING CODE REQUEST: [ ] Not applicable: facility located in non-coded area of state <br /> Date of referendum vote removing code requirements: <br /> Signature and Title of Local Official: Date: <br /> An inspection is required for all proposed facilities located in a code area which <br /> involves new construction, major renovating or change in occupancy i.e. any facility not <br /> currently used for the proposed usage. Inspection shall be in accordance with the E-3 <br /> Occupancy of the Minnesota Uniform Building Code. <br /> [ ] Facility meets requirements <br /> [ ] Facility does not meet requirements and cannot be occupied until orders are met. <br /> [ ] Facility does not meet requirements, but may temporarily be occupied pending <br /> completion of orders until <br /> Signature of Building Code Inspector: <br /> Certificate Number: Date: Comments: Reverse side <br />