HomeMy WebLinkAbout2014-08-06 MDH Interagency Request For Building Inspection INTERAGENCY REQUEST FOR BUILDING INSPECTION
CHILD CARE CENTERS
To Date: °7 I I " /
From: , (Licensor) Phone Number: `P 51— - 40 5 3,`
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.
11
Name of Program: i--A-ECS-Ass' U License Number: to (p 3 j i 3
Name of Facility:
Address: S S� Oa.i >2 sJ 01
Street City Zip C
Program Contact Person: Phone Number: 4eiS/—4311 - 6 79 9
Areas to be used: Classrooms to be used: Number/Age Ranges of Children:
❑ Basement ❑ Entire Facility 6 weeks to 16 months: / a-
❑ First Floor En Specific rooms listed below: 16 mos. To 33 months: ?-
• Second Floor ) rimA oc a^R-a-- 33 mos. To kindergarten:• cD
❑ Other k Kindergarten to 12 years:
Specify: Total: 16 a
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 inspector: ,o-} ,,�L\ , Phone Number: (PSI • '4.-3,—qq,.3 / x//QS
Agency Name: C,t dQX Po. K_ C L tyffl, , Date: g- tct-I f
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 `^'tom'"-
Revised 02/21/12
*************** -IND. XMT JOURNAL- **************** DATE AUG-07-2014 ***** TIME 11:33 ********
DATE/TIME = AUG-07-2014 11:32
JOURNAL No. = 36
COMM.RESULT = OK
PAGECS) = 001/001
DURATION = 00:00'35
FILE No. = 114
MODE = MEMORY TRANSMISSION
DESTINATION = 94317673
RECEIVED ID = / Fax Server
RESOLUTION = STD
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