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ci_ <br /> ...> -)..z.,INTERAGENCY REQUEST FOR INSPECTION `� ETURN TO: Division of Licensing <br /> 67 <br /> 4,, <br /> — MN Dept. Human Services <br /> y' j ,' /`7»C 1 _� <br /> 444 Lafayette Road <br /> A a St. Paul, MN 55155 <br /> /10.— AMw . <br /> TO: ,&t . -f 't • (rState/Local Health Inspector <br /> [ ] Local Building Code Inspector <br /> 0,41090 , P) ,3 i/ [ ] State/Local Fire Inspector <br /> .sem 6-3iy <br /> FROM: ,64-4- . '! ' , /' , Licensing Consultant DATE: , -/3 --f6 <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: /tQeL Proposed Use:��`��' ,1rtfaL <br /> Name of Program: Phone: VS a ya O <br /> Address: <br /> 4. -5O u)0-?),e 8 . 4 5 5 i <br /> Stree City Zip <br /> Area to be used: Numbers and Age Ranges of Participants: Facility Plans to <br /> Basement [ ] 6 wks. to 16 mos. Lf serve handicapped: <br /> First [✓f 16 mos. to 2 1/2 yrs. Yes ( ] <br /> Second [ ] 2 1/2 yrs. to 6 yrs. /j No ( ] <br /> Other ( 1 6 yrs. to 12 yrs. <br /> Specify: over 12 yrs. �o <br /> ( ] 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. <br /> [J,J 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: 4(\24v.4....._4 <br /> Certificate Number: i7i0 Date: 0 - 1Cj -y G Comments: Reverse side <br /> e_o,ittaPPA.9-� -7• k-c- - L/>s ' o <br />