HomeMy WebLinkAbout0022INTERAGENCY REQUEST FOR INSPECTION RETURN TO: Division of Licensing
HN Dept. of human Services
.444. 'Lafayette Road
TO: - St. :Paul. NN.'33133- 3842..
As,.
. [ ] State /Local Health Inspector ZyL
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Local Building Code Inspector
[. State /Local Fire. Inspector
FROM: Licensing Consultant Date:
Prior to issuing a -1 cense. verification is required that ..a facility is in compliance with
appropriate state or local codes for health. building and fire. 'Please complete the
appropriate section and return to the :Licensing Division with any orders :attached., A copy
of orders should be provided to the program. n
Name of . R p i e Proeosed use:
>s
Area to be used: Numbers and Age Ranges of Participants: Facility plans to
Basement (�%J .J.�keol - - '^ K 6 vha. to 16 nos. serve handicapped:
First I ] �. `� 16 no*. to 2.1 /2.yrs. Yes _CkI
Second" { ] 2 yrs.... to yrs.. No [ I
Other [ ] specify 6 yrs. to 12: yrs. 3 r1d
over 12 yrs. Over 18 Yrs.
HEALTR REQUEST: [:] Licensed ( ]':Not Licensed I }. Application left or mailed [ ] N/ _.
(
No orders necessary at time of inspection I ] Major orders issued-'
[ ] Minor orders issued_ [ ] Mayor revisions needed before license can be issued.
.: Data: Comments: Reverse aid .....
BU=INO CODE REQUM: (1 Not applicable; facility is located in a non -code area .:of star
Signature and Title of Local Official Date:
1
An inspection is..regmired, for all proposed facilities located in a code at" which Lnvalvc "
new construction.. =Joe renovating or slukuu JU oer_oanev i.e. any facility not currently
used for the proposed usage.
[ ] Facility meets requirsamuts
( ] Facility does not most requirements and cannot be occupied until orders are mat.
[ Facility does not most requirements. but may temporarily be occupied Pending couplet
of orders. until
7 ' Signatura of building Coda Inspector[
1
Certificate Number: — Date::
Comments: Reverse. side.