2013-request for building inspection

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� � 4 INTERAGENCY REQUEST FOR BUILDING INSPECTION , . �� ,�:,„S, .;., CHILD CARE CENTERS . � �MQ.n� To: �� $�.t.C�'0 � Date: �_�""�� �- � °'�°y`� 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 /�pz � c�� , �.=� c-, � � P- �� Y c-�rLv