HomeMy WebLinkAbout2012-12-11 Circle of Friends Adult Day Care License Inspection Verification P , b y ♦ .- �K .A
�a INTERAGENCY REQUEST FOR BUILDING INSPECTION
Oa 041 ' fitAi ADULT DAY CARE CENTERS
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To: Date: O9 _ale - I a-
From: , (Licensor) Phone Number:(051- 'f31- (o 53.6
Prior to issuing a license to provide adult day care, verification is required that a facility is in
compliance with appropriate state, county, and local building codes. 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: • License Number: / Ofp 4 1'c-4 , to
Name of Facility: Qit.ow—
Address: 510 (D ` l L& - I�•c.A- ea,--k4.46 , Va.L tf LAAL. S -O I-
Street City - Zip de
Program Contact Person: j A■ Phone Number: Cif Si - a' 7T - 5801
Area of Facility to be used:
Total Number of Participants:
Building-Inspection Results:
❑ Not Applicable: facility located in non -coded area.
Date of referendum vote removing code requirements:
Signature and Title of Local Official:
An inspection is required for all proposed facilities located in a code area which involves new construction, major
renovation, change in occupancy, or any facility not currently being used for adult day care.
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 . 1/4. t _ �Gi n , Phone Number: („$/ - I/49- yy3 1 X I S-
Agency Name: e, G( 0(a, 6:„.K., l'i 9 if ii1kA , Date: 12.- 11-12-
When inspection is complete, mail or fax this form and anyadditional orders to:
Minnesota Department of Human Services, Division of Licensing
P.O. Box 64242 3)70 r'
St.Paul, MN.55164 -0242 Y .. ', - . ` ,=,,; .,
Fax Number: 651- 297 -1490
Revised 5/08