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RECEIVEo <br /> APR I Z 2005 REQUEST for INSPECTION C/T,OF OR <br /> ONO <br /> To: ❑ State Fire Marshal <br /> ❑ Local Fire Inspector <br /> }p'Local Building Inspector <br /> ❑ State Health Inspector <br /> ❑ Local Health Inspector <br /> Date: April 6, 2005 <br /> From: Judy L. Brekke, (Licensor) Phone number: 651-297-4117 <br /> Prior to issuing a license, verification is required that a facility is in compliance with appropriate <br /> state or local codes for health, building, and fire. Please complete the applicable section and <br /> return to the Department of Human Services, Division of Licensing with any orders attached. A <br /> copy of the orders should also be provided to the program. <br /> Name of Facility: Cornerstone Church Proposed use: Child Care <br /> Name of Program: Orono Montessori School <br /> Address: 850 West Wayzata Blvd., Orono, MN 55356 <br /> Street City Zip Code <br /> Program contact person: Michael Kuruvilla Phone: 612-296-3518 <br /> Area to be used: Numbers/Age Ranges of Participants: Facility plans <br /> Basement ( ) 6 weeks to 16 months: 12 to serve <br /> First floor ( ) 16 months to 33 mos.: 21 handicapped: <br /> Second ( ) 33 mos. to kindergarten: 40 Yes ( ) <br /> Other ( ) kindergarten to 12 years: 4 No ( ) <br /> Specify: Total: 77 <br /> Health Request: ( ) Licensed ( ) Not Licensed ( )Application left or mailed <br /> ( ) No orders necessary at time of inspection ( ) Major orders issued <br /> ( ) Minor orders issued ( ) Major revisions needed before license can be issued <br /> Signature of Health Inspector: , Phone# <br /> Agency Name: , Date: <br /> Building Code Request: ( ) Not applicable: facility located in non-coded area <br /> Date referendum vote removing code requirements: <br /> Signature and Title of Local Official: <br /> An inspection is required for all proposed facilities located in a code area which involves new <br /> construction, major renovation or change in occupancy, (i.e. any facility not currently used for the <br /> proposed usage). <br /> Continued on next page ) <br />