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�������� <br /> w - � , <br /> �� ..;j; � 1 lf�., <br /> ;� INTERAGENCY REQUEST FOR FIRE INSPECTION <br /> CHILD CARE CENTERS <br /> a.�,.,..�.. t ,..�.rN„�mans�.� e <br /> To: ��I/y1Z5 vQn �y �� �t�`Nc1`C � ❑ State Fire Marshal <br /> (�� O�� �„pn �� 1� Local Fire Inspector <br /> /� <br /> �a V��a�riN 55 3� Date: 0"o�-I� <br /> � <br /> From: KC��l�170.�1`,� 1A71r1C VIQr'1K (Licensor) PhoneNumber:�'/ '�3I-6$30 �/I��j�-b,s28 <br /> A fire inspection under the Minnesota State Fire Code is required for all new child care facilities, and for a <br /> proposed change of occupancy The facility must be inspected within 12 months before initial licensure. The <br /> Commissi�ner of DHS must not grant a license untii written approval of compliance with the state fire code <br /> nas been received from the fire marshal with jurisdiction. <br /> Name of Program: W � ��4� �Mu,r1�.{'� .S�C�O I License Number:_ �C'��-IO�D� <br /> Name of Facility: �YI w �(�Ol.t� �,pmMLt.n.t..�Z� .X�o D ' <br /> Address: �� 7 ��u wtQ�'°t�. �r11/"Pi �pn . �A.�.� �/\} SS �S�o <br /> Street City Zip Code <br /> Program Contact Person:��� a �-�/'�,1'1 ��5�1 Phone Number: (��,- ��'-j 8 g <br /> Areas to be used Z ssrooms to be used Number/Aqe Ranges of Children <br /> �; Basement ❑ ntire Facillty 6 weeks to 16 months: <br /> -7. ' r; First Floor ❑ pecific rooms listed below: 1� mos. to 33 monihs: <br /> ! - Seccr�d Floor 33 mos to kindergarten _�_ <br /> �� ^ Oth�r _ _ Kindergarter to 12 years <br /> - Specify Total: �_ <br /> Fire Inspection Results: <br /> r Facility meets requirements of the fire c �`v�� ��� <br /> � ���� � <br /> Note: If entire facility meets �-4 � �dicate by <br /> checking this box ❑ �� Q.ei1�. <br /> 1�°�'� <br /> � Facility does not meet requirements of 1 are met. <br /> ❑ Facility does not meet requirements; bu � � � — � _(date), <br /> pending completion of orders. ,r /G� �� <br /> �..�J <br /> Comments: �/ <br /> l�on �I. I <br /> T'�X�y �ls�'V`., �'SZ��Z3 — <br /> Signature of Fire Inspector: �� <br /> Agency Name , uate. <br /> When inspection is complete, mail or fax this form and any additional orders to: <br /> Minnesota Department of Human Services, Division of Licensing <br /> P.O. Box 64242 DNS Use:Only _ <br /> St.Paul, MN 55164-0242 oate: �� � � ; <br /> Fax Niimhar• R�1���_���'t <br />