HomeMy WebLinkAbout2013-request for building inspection � �
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INTERAGENCY REQUEST FOR BUILDING INSPECTION
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�� � ,�:,„S, .;., CHILD CARE CENTERS
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To: ��� �$�.t.C�'0 � Date: �_�""��
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From: , (Licensor) Phone Number: (OS� – �3i � '652g
Prior to issuing a license to provide child care, verification is required that a facility is in compliance with
appropriate state, county, and local building codes (Minnesota Rules, part 9503.0155, subpart 1). Please
complete this form and return it 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 Program: W icense Number: �
M1fame of Facility:
Address: ,�1 l�'" _LJ�til1�`-� ,S.S ?J J `�'
Street City Zip Code
Program Contact Person: �Q' "�-'^'' �h���� Phone Number: �p��–'�a'�Q�' �,�a
Areas to be used: � Classrooms to be used: Number/Aqe Ranqes of Children:
❑ Basement �� ❑ Entire Facility 6 weeks to 16 months:
❑ First Floor � Specific rooms listed below: 16 mos. To 33 months:
❑ Second Floor �
33 mos. To kindergarten:�
❑ Other Kindergarten to 12 years:
Specify: K� �� �� Total:�—�
Building Inspection Results: �,,sn} ��L �✓\
�.r–.,�
❑ Not Applicable: facility located in non-coded area.
Date of referendum vote removing code requirements:
Signature and Title of Local Official:
�Facility meets Cuildir�g ccde requiremer,ts.
❑ Facility does not meet requirements and cannot be occupied until orders are met.
❑ Facility does not meet requirements, but may temporarily be occupied until: (date),
pending completion of orders.
Signature of Building inspector: , Phone Number: 4�Z- 2 / '�!– Y a Z�
Agency Name: �1 � ��'� ����� , Date: 7' 3 / ' � �� �
When inspection is complete, mail or fax this form and any additional orders to: '
Minnesota Department of Human Services, Division of Licensing
P.O. Box 64242
St.Paul, MN 55164-0242 RECEIVED
Fax Number: 651-431-7673 ,
JAN 2� 2013 '� �
�
C�TY OF ORONO Revised 02/21/12
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TRANSMISSION VERIFICATION REPORT
TIME : 07131/2�13 14: 41
NAME : ORONO
F�X : 9522494616
TEL : 9522494615
SER. # : BROL2J412694
DATE,TIME 07I31 14: 41
FAX NO./NAME 6514316528
DURATION 0�: 0�: 00
PAGE(S) 0�
RESULT EUSV
MODE ST�NDARD
EUSV: BUS`,'IhJU RESPONSE
INTERAGENCY REQUEST FOR �UILQIN� IhISPECTfON
� ��_ CHiLb CARE CENTERS
Ta: r�� �$�p�� f Date: —
d r
� � /I.tJ7'��
From: , (Licensor) Phane Number: �D�� � ��� ! ����
I'rior ta issuing a license to provide child care, uerification is required that a facifity is in compfiance with
apprapriate state, counky, and Focai building eodes (Minnesofia Rules, part 9503.0156, subpart 1), Please
complete this fprm and re#urn it to the Deparkment qf Wuman Services, Div'tsion of Licensing with any orders
�ttached. A copy of the arders should also be pro�ided to the progr�rrt.
Narrle of prQgram: icense Number: �]
Name of Facility:
Address: ��� � �� �� ��
Street City Zip Code
Program Contact Pe�son: ��y �G��1C��'7 Phone Nu�nnber- �D�����"�L3� ���6
Areas.#o_be__used: Classrooms to be used; Number/Aqe Ran�ces of Chiidren�
CI B�sement � �1 Entir� F�cility 6 weeks to 16 months�
❑ First Fiaor �/Specific raoms listed below, 16 mos. T� 33 manths�
❑ Second Floor �r~ 33 mas. To kindergarten: ��t
—��,�_
p Other Kindergarten to 12 years:
Specify: � �� ��� Totial:�
6uildin4 Inspection Results; �`D# ��,� ��Y1
�`r,��;
❑ Not Applic�ble: facility IoC�ted in non-coded area.
D�te uf referendum �pte remo�ing �4�e requirements;
Sign2ture and Title af Locaf Offfcial; �