1325 Eagandale Ct - Everydale Living Adult Daycare InspectionTo:
From: 0.atA b‘.
Comments: f ey4Q,c,
Name of Program: 7,l 4 9 Ltv A
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St Paul, MN 55164 -0242
Fax Number: 651- 297 -1490
INTERAGENCY REQUEST FOR FIRE INSPECTION
90
ADULT DAY CARE CENTERS
❑ State Fire Marshal
A Local Fire Inspector
Date: 5-2,1-11
, (Licensor) Phone Number: `"Q S1 - 3 f
A fire inspection under the Minnesota State Fire Code is required for all adult day care facilities prior to initial
licensure and upon a change of occupancy, as applicable. The Commissioner of DHS must not grant a
license until written approval of compliance with the state fire code has been received from a State Fire
Marshal, or from a local fire inspector if approved by the State Fire Marshal Division.
Name of Facility: 1
Address? a 0 c ACtk C , ce' t24 r E �,_ S � (3 --1
reet City Zip Code
Program Contact Person: Aoki Mot Phone Number: (.Q kL LO Y l C JC 0 til 1
Area of facility to be used:
Total Number of Participants: k.0
Fire Inspection Results:
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/Facility meets requirements of the fire code.
❑ Facility does not meet requirements of the fire code and cannot be occupied until orders are met.
❑ Facility does not meet requirements, but may temporarily be occupied until (date),
pending completion of orders.
Occupancy designation by Fire Inspector.
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License Number: t &Qa 5 d (
, Phone #: 60 lJ
, Date: , 1 6 11
Signatu�r. of Fie Inspector .
Agency Name:
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
6
Revised 5108
Receipt Date
Receipt Number
City of Eagan
Cash Receipt
EVERYDAY LIVING /CK #1336
1325 EAGANDALE CT
6/29/2011
170746
1221.4216
DAYCARE INSP. /1325 EAGANDALE
Total Receipt Amount
121197 6:31:06
50.00
50.00