HomeMy WebLinkAbout2012-08-28 Child Care Center OPH Inspection Sign Off I,
INTERAGENCY REQUEST FOR BUILDING INSPECTION
RECEIVED,, C ' RE CENTERS
To. AUG 2 4 2012 Date: O$ L d-
City of Oak Park Heights
From: ' ■ . 4 _ A/111A _ _ AC■ • • . Number: to I - 4 31 — (oS3,6
•
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 U be provided to the program.
Name of Program: U License Number: / D (' 3 l8 3
Name of Facility:
Address: `J S 41 S CL-0 D • 00--i. 1� o 4& ftJ.\j S S' $a
Street City Zip lli
Program Contact Person: 9 i -+"4 Phone Number: g ( O- 9 (07 - q 34a-
Areas to be used: Classrooms to be used: Number /Age Ranges of Children:
❑ Basement G2rEntire Facility 6 weeks to 16 months: 1.?.
[First Floor ❑ Specific rooms listed below: 16 mos. To 33 months: a- I?
❑ Second Floor 33 mos. To kindergarten: S
p Other Kindergarten to 12 years: a.-o
Specify: Total: 1 i 0
Building Inspection Results:
❑ Not Applicable: facility located in non -coded area.
Date of referendum vote removing code requirements:
Signature and Title of Local Official:
Facility meets building code requirements.
❑ 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 inspecto • fO _ (1 4 1,7 - ' 0,k) , Phone Number: � , Si - '139- 4 / 4 /37
Agency Name: t Pan JC 8 h te , Date: - .Z 8 -1 Z
V
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
Fax Number: 651 -431 -7673
Revised 02/21/12