HomeMy WebLinkAboutrequest for inspection _.,_��_.:�:iC: 3:.�C:S: :.^,2 �:;Src,CTIvi� RETi.:R.*1 TO•
� .: � Division of Licensing
' ��" �''���`' �'' ���'a-�. ��tcL����,_-<,._y�. IflV Dept. of Human Ser�ices
T0: '- ' � V`�f'` � 'Lt''"-� ; � 444 Lafayette Road
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�. � St. Paul, MN 55155-3842
,� ��, r3 �-,� � � �
�--, j � y� [ J" State/Local Health Inspector
�' 1k_(�..' �3 c�.�...�y � ( �h - [ ] Local Building Code Inspector
�' U 5,0'�3 [ ] State/Local Fire Inspector
�� i � �
FROM: /�.��- .�.;_2ti��..��'2,� , Licensing Consultant Date:� S^ �
?rior to issuing a license, verification is required that a facility is in compliance vit�:
appropriate state or local codes for health, building and fire. Please complete the
appropriate section and return to the Licensing Division with any orders attached. A copy
of orders should be provided to the program.
Name of Facilitv:�� ��-v��� � � �V" � �
�''`'°`�"Y' C� Proposed use �,�-��
I ��
Name of Pro ram: �� �� �_�" � � � � � Phone: ` - - --_ ��.3�.C.
� � �r- i J � `� I l ,
Ad dr e s s:�S�6 S i',?��"7 '�'-Z'�-C�a,l� `-' ' � f- � _
'�'�''t�'' ��-.�,., `-=�.� :Lr. S� 3 S"� �
street city � zJ�p � county
Contact Person:-��-Zoc�.��v�n ��.2,��,�-,-r, �c;.�. ��1�_ � ! r y
— Phone ' ,
Address :
street city zip
Area to be used: Numbers and .,ge Ranges oT Participants : Facility plans to
Basement (,�' 6 wks . to 16 mos. serve handicapped:
First ( J 16 mos . to 2 1/2 yrs . Yes [ � ?
Second [ ] 2 1/2 yrs . to 6 yrs . �� No �
Other [ j spec ify 6 yrs . to 12 yrs. �' ����� [ ,
over 12 yrs . Over 18 yzs.
-- - ����a�a��
HEALTH REQUEST: ( ] Licensed [ ] Not Licensed ( j Application left or mailed [ ] N/F
[ J No orders necessary at time of inspection ( ] ?iajor orders issued
[ j Minor orders issued [ j Major revisions needed before license can be issued
Signature: Date: Comments: Reverse side
BUILDING CODE REQUEST: [ ] Not applicable; facility is located in a non-code area or state
Signature and Title of Z.ocal Official BQ��:
An inspection is required for all proposed facilities Located in a code area which involved
new construction, major renovating or chanQe in occupancv i.e. any facility not currently
used for the proposed usage.
(}C] Facility meets requirements
[ J Facility does not meet requirements and cannot be occupied until orders are :�et .
[ J Facility does not meet requirements, but :nay teWporarily be occupied pending completio:
of orders , until
Signature of Huilding Code Inspector: �i�,� ���e..�_
Certificate Number: I ZSSd Date : � � (I� �j 2
Comments: Reverse side.
FIRE COOE.REQUEST: A fire inspection is required for all proposed facilities .
ficillti�� loc�t��l !n as� tr�a of th� scate und�r ch� Uni;�r„� �it�in= ��t �yit
E-� oceupaney r�quir�nt: of thac code in a��icion co �policablt fir� co�i� r�Qy������
(If Zoch cod�: ad�reaa a sptcific ar�a. the U8C Cakes pr�c, :nc� ov�= ch• fir• cv��. � `s.
F�cilltiei lout�d 1n an ars• of [h� ttate n_.� under the U-�.::or+� Duildin� Cad� mus: -,je:
�pp11ca5Ie Cire cod� r�Quirernents.
In either inscance, the ?iinntsota Unifor� Tire Code applies.
�j Facilicy �eecs requir�ments of th� fire co�+�.
[� Facilicy does noG �a��t r�quirern�nts of the .`ire code anc� can�oC bt occupie�
un:il orders are �c.
[� F�ei: ity da�` not ��t r�quir�n�nc:, DL: r�ay c�n�por�rily Ds oceupi�d p�ndi• �
co�npletion o. orr�ers urici?
Signacure of Fire� Znsp�ctor: _ �i,� �;y�_ •
,�� Dace: 5"-� (-�jZ
Co�encs: De1ov.
CO'i`*�:S:
FIRE COOE.REQUEST: A fire inspection is required for all proposed facili �ies.
facilici�s loc�c�� in an ar�a of th� scat� und�r Ch� Unif�r„i �il�in= ��� ��t
L-� occupaney r�qvir�nt• ot tl�ac code trs a��icion co a licabl� firt ca�i� r� y��� `��
PP
(jf toch cod�� ad�ress � sp�cific ar�a, the U8C Cakss prec• :nc� ov�r ch� fireacoA��^�S'
Tacilicitt lout�d in sn ar�a of cht •tace noc under the I1�.:forn Euildin` Cod� �us: —,�.:
�ppllcable fire code r�quirersenca.
In eith�r inseanc�. the lSinnesota Unlfor� Tire Code applies.
� Faci2lty meets requireraents of th� fire co�+e.
[� Tacility does noC m�ec reQuirernencs of th� °ire code anc� canloc be occup:e�
uncil orders are �ec.
[� f�e1: Sty dots not ��t rtQutrt*+�ntf, b;:: �n�y ��,�p�r�rlly b� oeevpi�d p�n!:• �
co*apl�Cion o� er�ers unci!
Signscurs of Fire• Insp�ctor: � �y.t� •
L1a.e: r -I 1-`1Z
Co�e n c s: D�1 o v.
CO*^•�.'S: