4194 Pilot Knob Rd - MN Dept. of Human Svcs. - Daycare Inspection ResultsFrom:
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A fire inspection under the Minnesota State Fire Code is required for all new child care facilities, and for a
proposed change of occupancy. The facility must be inspected within 12 months before initial licensure. The
Commissioner of DHS must not grant a license until written approval of compliance with the state fire code
has been received from the fire marshal with jurisdiction.
Name of Program: l
PX.C,k S qeS License Number: / q 83 0
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Name of Facility:
Address:
Program Contact
Areas to be used:
ij Basement
First Floor
• Second Floor
▪ Other
Specify:
Fire Inspection Results:
Comments:
Signature of Fire Inspector:
Agency Nam
INTERAGENCY REQUEST FOR FIRE INSPECTION
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Street City
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Person:
Classrooms to be used:
*Entire Facility
p Specific rooms listed below:
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1101141
CHILD CARE CENTERS
(=I State Fire Marshal
34 Local Fire Inspector
, Date:
Date:
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- 297-1490
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, (Licensor) Phone Number: OSI '4WD 631 c l
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Zip Code
Phone Number: CO a 34)-5 98FZI
Number/Aqe Ranqes of Children:
6 weeks to 16 months: /4,
16 mos. to 33 months:
33 mos. to kindergarten: \
0
Kindergarten to 12 years: j 40
Total:
A Facility meets requirements of the fire code.
Note: If entire facility meets 1-4 requirements of the Minnesota State Fire Code, indicate by
checking this box E.
o Facility does not meet requirements of the fire code and cannot be occupied until orders are met.
ci Facility does not meet requirements, but may temporarily be occupied until (date),
pending completion of orders.
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Phone Number
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Revised 5/08
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From: ` Oltrl . 60,1 tnD(
Address:
Program Contact Person: iyy► YV1U�t d
Signature of Building inspector:
Agency Name:
41 Pi 1off'knob Rd
Street
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/606 7/
INTERAGENCY REQUEST FOR BUILDING INSPECTION
CHILD CARE CENTERS
Date: 1=9"
RECEIVED
JUN 2 2 2011
, (Licensor) Phone Number: t — a 1(P — 6s(4.
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.
Name of Program: f(' License Number: 10 10
Name of Facility:
Areas to be used: I ssrooms to be used: Number /Aqe Ranges of Children:
❑ Basement Entire Facility 6 weeks to 16 months: I(0
A First Floor ❑ Specific rooms listed below: 16 mos. To 33 months: dSr
❑ Second Floor 33 mos. To kindergarten: »n
❑ Other Kindergarten to 12 years:
Specify: Total: 104
Building Inspection Results:
Ei 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.
rA0 SSte
City v Zip Code
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 - 297 -1490
Phone Number: era `3495 -y8 D
Phone Number: (L - i) G 7S , 153
, Date: ti
to
Revised 5/08