Laserfiche WebLink
INTERAGENCY REQUEST FOR INSPECTION RETURN TO: Division of Licensing <br /> MN Dept. Human Services <br /> Gm16L- _ __ 444 Lafayette Road <br /> MAR Q 1 1999 St. Paul, MN 55155 <br /> TO: ! �. 6 [ J State/Local Health Inspector <br /> �3a�11 Y Ur UKO��Local Building Code Inspector <br /> may, <br /> [,'1 State/Local Fire Inspector <br /> FROM: Licensing Consultant DATE: 2'Z- S <br /> 6Si .a yd 6315/ <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. ��// (11 ``"" <br /> Name of Facility: Proposed Use:L/ZCl�� <br /> `! 6JZ y7S���z� <br /> Name of Program: Phone: <br /> 4a� <br /> Address:�� City 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. Yes [ ] <br /> Second [ ] 2 1/2 yrs. to 6 yrs. _ / No ( ] <br /> Other [ ] 6 yrs. to 12 yrs. )s <br /> Specify: over 12 yrs. <br /> HEALTH REQUEST: ( ] Licensed ( ] Not Licensed [ ] Application left or mailed <br /> ( J No orders necessary at time of inspection ( J Major orders issued <br /> [ J 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 located in non-coded area of state <br /> Date of referendum vote removing code requirements: <br /> Signature and Title of Local Official:QzluA( Date: ' <br /> An inspection is required for all proposed fac ities 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 /> �Pq 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 />