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_.,_��_.:�:iC: 3:.�C:S: :.^,2 �:;Src,CTIvi� RETi.:R.*1 TO• <br /> � .: � Division of Licensing <br /> ' ��" �''���`' �'' ���'a-�. ��tcL����,_-<,._y�. IflV Dept. of Human Ser�ices <br /> T0: '- ' � V`�f'` � 'Lt''"-� ; � 444 Lafayette Road <br /> J-- <br /> �. � St. Paul, MN 55155-3842 <br /> ,� ��, r3 �-,� � � � <br /> �--, j � y� [ J" State/Local Health Inspector <br /> �' 1k_(�..' �3 c�.�...�y � ( �h - [ ] Local Building Code Inspector <br /> �' U 5,0'�3 [ ] State/Local Fire Inspector <br /> �� i � � <br /> FROM: /�.��- .�.;_2ti��..��'2,� , Licensing Consultant Date:� S^ � <br /> ?rior to issuing a license, verification is required that a facility is in compliance vit�: <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 Facilitv:�� ��-v��� � � �V" � � <br /> �''`'°`�"Y' C� Proposed use �,�-�� <br /> I �� <br /> Name of Pro ram: �� �� �_�" � � � � � Phone: ` - - --_ ��.3�.C. <br /> � � �r- i J � `� I l , <br /> Ad dr e s s:�S�6 S i',?��"7 '�'-Z'�-C�a,l� `-' ' � f- � _ <br /> '�'�''t�'' ��-.�,., `-=�.� :Lr. S� 3 S"� � <br /> street city � zJ�p � county <br /> Contact Person:-��-Zoc�.��v�n ��.2,��,�-,-r, �c;.�. ��1�_ � ! r y <br /> — Phone ' , <br /> Address : <br /> street city zip <br /> Area to be used: Numbers and .,ge Ranges oT Participants : Facility plans to <br /> Basement (,�' 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 . �� No � <br /> Other [ j spec ify 6 yrs . to 12 yrs. �' ����� [ , <br /> over 12 yrs . Over 18 yzs. <br /> -- - ����a�a�� <br /> HEALTH REQUEST: ( ] Licensed [ ] Not Licensed ( j Application left or mailed [ ] N/F <br /> [ J No orders necessary at time of inspection ( ] ?iajor 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 is located in a non-code area or state <br /> Signature and Title of Z.ocal Official BQ��: <br /> An inspection is required for all proposed facilities Located in a code area which involved <br /> new construction, major renovating or chanQe in occupancv i.e. any facility not currently <br /> used for the proposed usage. <br /> (}C] Facility meets requirements <br /> [ J Facility does not meet requirements and cannot be occupied until orders are :�et . <br /> [ J Facility does not meet requirements, but :nay teWporarily be occupied pending completio: <br /> of orders , until <br /> Signature of Huilding Code Inspector: �i�,� ���e..�_ <br /> Certificate Number: I ZSSd Date : � � (I� �j 2 <br /> Comments: Reverse side. <br />