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DHS LICENSING � 6122971490 09/�3/97 11 :46 � :01 /02 N0:348 <br /> POat-iY"Fax Noke 7671 Delo ._- _�� p�9es� �- <br /> To Frpm�� J RETURN T�: Divi$ion of LicensinG <br /> MN De�it. Human SPYvicBs <br /> ColoePt �� 444 Lafayette Road <br /> / /' St. Paul, MN 55155 <br /> Phon�N �no�e r �C'Jo — (� .�� <br /> �. <br /> �-�YN � -p��p F�n� j ] 5tate/Local Howlth In�pector <br /> ( j Local B�ilding Code Irispoctor <br /> {,/f StaCe/Local Fire inagector <br /> FRort: ���T� �y��,.��� .:,.f7 �t"/�f� , Licensinq Conaultant Dl�►'��: J-�� '�7 <br /> g �f-G';�/y� � <br /> Priar ta iseuin a licen��, ve ifieation ig re ired thAt a fa�ility i� in compliance wit.`. <br /> appropriate etate �r 1oca1 codes for health, building and fire. Please complete the <br /> appropriate section and raturn to thQ Licenaing Divi�ion with any arder� attached. A cop: <br /> of orders �should 2ae pravided to thQ pzoyiam. <br /> Nc�me af Facilitys PropoaQd us►o: � «` �l�-'�_ <br /> Name of Program: �-�� ��,fC��'(�'` '`, PhQne: �OC7y4 - <br /> A�dresa: �S ��� r1 _f�(�C c�• � 7��J �5��� <br /> Straet city zip <br /> Area to be used: P�umbera and Age Ranges of Participe.nts: F'acility Plans to <br /> Bagement O 6 wke. tv 15 moe. � eQrve handicapped: <br /> Fire�t ( ) I6 mos. to 2 1/2 yre. Yed ( 1 <br /> Second O 2 1/2 yre. to 6 yra. � N� f ] <br /> oth�r [ J 6 yre. to 12 yr9. <br /> specify_ �__� over 12 yra. <br /> HEALTH REQUEST: O Liceneed � ) Not Licensed [ ] Applicatian left or maile� <br /> ( j No ordera nQceseary at time af inapeGtion ( J Metjor ordere issued <br /> [ J Minar ord�ra iaaued ( � M�jor reviaions neaded before l�cenee can be isoued <br /> Signature: �� � Date: Commenta: RovorQa side <br /> BUILDZNG CODE REQUEST: ( � Not applicable: facility l4cated in non-caded area of state <br /> Datc of referendum ��ote rvmdving codc roquirem�nt�: <br /> 5iqnature and Title o£ Lacal Official: I}at�: <br /> An inapaction i8 required fOr all propoeed faci].itiee locatea in a code arwa wh�ch <br /> involves new construction, major renovatinq or ch�nq i:1 Q�cupancy i.a. any facility not <br /> currently ueed for the PrO�66Bd ueage, <br /> (�) Facility meats requirements <br /> [ ] Facility dosa not meeC requir�ments and cannoC be occupied until ordera are met <br /> j ) Facility doeg not meet requiremencs, but may temporarily be occupied pending <br /> comgletior► of orders until � <br /> signature of Building Code Inspector: [�/ ,,� � <br /> CeL'tificate Numbt:rt �Z�i�% Date: �� 3 � Commante: Revaraa sic�e <br /> -�7_---- y�� �r,�ya <br /> ��7YJ�Pl.:e � �P��1-r�.' ��j r��/_� �� ' _ <br />