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INTERAGENCY REQUEST FOR INSPECTION RETURN TO: :'Division of Licensing.
-RN. Dept. Human Services
444 Lafayette Road
St. Paul, .::HN 55155 -
.TO: _ [. ] State /Local Health Inspector
[]
Local Building : Code Inspector
• [.] State /Local Fire Inspector •
FROM: ,..Licensing Consultant DATE
Prior to issuing a license, verification is required that a facility is in compliance with
appropriate state or local codes for health, building and fire.. please: complote; the
appropriate': section and return to the Licensing :Division with any orders attached. A!COPY
of orders should, be provided to the.. program..
Name of Facility: - Proposed Use:.
Name of Program: Phone:
Address: : 21
Street City P
Area to be used: Numbers and Age Ranges of Participants: Facility Plans to
Basement 1 - 6 Wks. to .16 mos. serve handicapped:
First [. ] : mos. `to 2 1/2 yrs. _ Yea [ -]. I !
Second [ ]' 2 1 /2. : yrs. to 6 yrs. No 64
other [ [ 6 yrs. to 12 yrs.
Specify:. over 12: yrs.
HEALTH REQUEST: [] Licensed [ ]Not Licensed [ j Application left or :mailed
( ]: No orders neceseary,at time of inspection ( ] major orders issued. r
( ]- Minor orders issued [ ] Major revisions needed before license can be issued,
Signature.. Dater Comments: Reverse aide
BUILDING CODE REQUEST: (]: Not applicable: :facility located in non - coded area of state
Date of referendum vote' removing :. code . requirements: t
Signature and Title of Local Official: Date: t,
An inspection is required for all proposed facilities located in a node area which
involves now construction, major renovating . or chance in occupancy i.e. any facility not
currently used for the proposed usage..
[ ).. Facility meets requirements K
[ ].. Facility does not meet requirements and cannot be occupied until orders are met.
[] Facility does not meet requirements, but may temporarily be occupied pending
completion of 'orders until -
...Signature of Building Code Inspector.:
Certificate Number:. Date: Comments: Reverse side
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