HomeMy WebLinkAboutInteragency Request for Inspection RECEIVEo
APR I Z 2005 REQUEST for INSPECTION C/T,OF OR
ONO
To: ❑ State Fire Marshal
❑ Local Fire Inspector
}p'Local Building Inspector
❑ State Health Inspector
❑ Local Health Inspector
Date: April 6, 2005
From: Judy L. Brekke, (Licensor) Phone number: 651-297-4117
Prior to issuing a license, verification is required that a facility is in compliance with appropriate
state or local codes for health, building, and fire. Please complete the applicable section and
return to the Department of Human Services, Division of Licensing with any orders attached. A
copy of the orders should also be provided to the program.
Name of Facility: Cornerstone Church Proposed use: Child Care
Name of Program: Orono Montessori School
Address: 850 West Wayzata Blvd., Orono, MN 55356
Street City Zip Code
Program contact person: Michael Kuruvilla Phone: 612-296-3518
Area to be used: Numbers/Age Ranges of Participants: Facility plans
Basement ( ) 6 weeks to 16 months: 12 to serve
First floor ( ) 16 months to 33 mos.: 21 handicapped:
Second ( ) 33 mos. to kindergarten: 40 Yes ( )
Other ( ) kindergarten to 12 years: 4 No ( )
Specify: Total: 77
Health Request: ( ) Licensed ( ) Not Licensed ( )Application left or mailed
( ) No orders necessary at time of inspection ( ) Major orders issued
( ) Minor orders issued ( ) Major revisions needed before license can be issued
Signature of Health Inspector: , Phone#
Agency Name: , Date:
Building Code Request: ( ) Not applicable: facility located in non-coded area
Date referendum vote removing code requirements:
Signature and Title of Local Official:
An inspection is required for all proposed facilities located in a code area which involves new
construction, major renovation or change in occupancy, (i.e. any facility not currently used for the
proposed usage).
Continued on next page )
Page 2
Building Code Request (continued)
( ) Facility meets requirements building code requirements
()C) Facilit does not meet requirements and cannot be occupied until orders are met
Fi r I';<.L-cJ /4 1!_rmoPet-/cove c®.+ Ii/Wc—€
( ) Facility does not meet requirements, but may temporarily be occupied until
(date), pending� completion of orders.
Signature of Building Inspector: i,�o COA-vv t y\. , Phone# 45Z-Z`i9- 462.5"Certificate Number: 12$O a Date: 14- 2-'1 - 6 S
a
Fire Code Request: A fire inspection under the Minnesota Uniform Fire Code is
required for all proposed facilities. The facility must be inspected within 12 months before initial
licensure. The Commissioner of DHS must not grant a license until written approval of
compliance with the MN Uniform Fire Code has been received from the fire marshal with
jurisdiction.
( ) Facility meets requirements of the fire code
(V) Facility does not meet requirements of the fire code and cannot be occupied
until orders are met sss-c ,,ore A-io"Je
( ) Facility does not meet requirements, but may temporarily be occupied until
(date), pending completion of orders.
Signature of Fire Inspector: A (6(1 (eyes , Phone# (' 2 -'I%c 2 30')
Agency Name: OP 0Am r 11nA,n6fna4 , Date: e-1-z4 -a S
Comments:
When the inspection is completed, mail or fax this form to:
Minnesota Department of Human Services
Division of Licensing
444 Lafayette Road
St. Paul, MN 55155-3842
Fax number: (651) 297-1490
Updated: 2-26-04