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INTERAGENCY REQUEST FOR INSPECTION kElURN TO: Division of Licensing <br /> MN Dept. of Human Services <br /> 444 Lafayette Road <br /> TO St. Paul, MN 55155-3842 <br /> [ ] State/Local Health Inspector <br /> [ <br /> [ ] kocal Building Code Inspector <br /> State/Local Fire Inspector <br /> FROM: ' ens in Consultant Date: <br /> license, v g <br /> Prior to issuing a is 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: Pro osed use: <br /> Name of PrORrRm: O �'�� one: 3 - 3 3 <br /> Address: 3��' /��'� /, �J�-c7n-� y S 3S 6 <br /> street ( city zip county <br /> Contact Person. �� r Phone: <br /> Address: <br /> street city zip <br /> Area to be used: Numbers and Age Ranges of Participants: Facility plans to <br /> Basement [ j 6 wks. to 16 mos. serve handicapped: <br /> First [ J 16 mos. to 2 1/2 yrs. Yes [ ] <br /> Second [ ] 2 1/2 yrs. to 6 yrs. 60 No ( j <br /> Other [ ] specify 6 yrs. to 12 yrs. <br /> over 12 yrs. Over 18 yrs. <br /> HEALTH REQUEST: ( ] Licensed [ ] Not Licensed [ ] Application left or mailed [ J N/A <br /> ( ] No orders necessary at time of inspection [ ] Major orders issued <br /> [ ] Minor orders issued [ J Major revisions needed before license can be issued <br /> Signature: Date: Comments: Reverse side. <br /> BUILDING CODE REQUEST: ( ] Not applicable; facility is located in a non-code area of state . <br /> Signature and Title of Local Official 6(_0C, GFS L L. Date: r2-,L- 'I'f <br /> An inspection is required for all proposed facilities located in a code area which involved <br /> new construction, major renovating or change _tn occupancy i.e. any facility not currently <br /> used for the proposed usage. <br /> [)Q Facility meats requirements <br /> [ J Facility does not meet requirements and cannot be occupied until orders are met. <br /> [ J Facility does not meet requirements, but may temporarily be occupied pending completio <br /> of orders, until <br /> Signature of Building Code Inspector: r4oCertificate Number:Number: IZ�/o Date: t2. - 5y <br /> Comments: Reverse side. <br />