550 Opperman Dr -Daycare Insp
Use BLUE or BLACK Ink
r
For Office Use
I CJ.~ I
Permit
1t of an
C lUV O1 aR
U#: J E 1 Permit Fee: V
3830 Pilot Knob Road I I
Eagan MN 55122 1 Date Received: I
Phone: (651) 675-5675 1 1
Fax: (651) 675-5694 1 Staff: j
L-----------------I
2012 COMMERCIAL BUILDING PERMIT APPLICATION
Date: 3 -2-1 ~ 2- Site Address: 0 12 r a ~ ~
Tenant Name: C Lct G n Ec r- L+ (Tenant is: New / Existing) Suite
1 Lich cx La-, ! +n A Ca f Former Tenant:
Name: Phone:
PROPERTY OWNER Address / City / Zip:
Applicant is: Owner Contractor
TYPE OF WORK Description of work: Q C, / h 2 C:~ s
Construction Cost:
Name: License
CONTRACTOR Address: City:
State: Zip: Phone: Z -
Contact: G- 6~4 Email:
Name: Registration M
ARCHITECT/ Address: City:
ENGINEER
State: Zip: Phone:
Contact Person: Email:
Licensed plumber installing new sewer/water service: Phone
NOTE. Plans and supporting documents that you submit are considered to be public information. Portions of
the information may be classified as non-public if you provide specific reasons that would permit the City to
conclude that the are trade secrets.
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage.
Call 48 hours before you intend to dig to receive locates of underground utilities. www.gopherstatEionecall.org
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and
codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a
permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans.
X eighon x
Applican s Pri ed Name Applicant's Signature
Page 1 of 3
INTERAGENCY REQUEST FOR BUILDING INSPECTION
CHILD CARE CENTERS
To: CCU, Date
From: QL II (Licensor) Phone Number: Ca 5 3 I !a S 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.
Name of Program yMCA L., ed..... &-a4g- UAIA"Anse Number: l b (o a- -19 7
Name of Facility:
Address: b t.a i'YI N SS l2 3
Ste L / Zip Code
Program Contact Person: Phone Number: (a 0 S a
Areas to be used: Classrooms to be used: Number/Age Ranges of Children:
❑ Basement PJ'Entire Facility 6 weeks to 16 months:- 0
,"First Floor ❑ Specific rooms listed below: 16 mos. To 33 months:_ 3
❑ Second Floor 33 mos. To kindergarten: / (o,;,
❑ Other Kindergarten to 12 years:
Specify: Total`. c; 4
Building Inspection Results: '
rl, Not Applicable: facility located in non-coded area. - - -
Date of referendum vote removing code requirements:
Signature and Title of Local Official: -
La/Facility meets building code requirements.
❑ Facility does not meet requirements and cannot be occupied until orders are meta
❑ Facility does not meet requirements, but may temporarily be occupied until: (date),
pending completion of orders.
Signature of Building inspector: Z;4-. Phone Number: GS/--G7S " Sw'!,(
Agency Name: 1:9 W 9-OLfAem , Date: .3l ~f /SL
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: 651431-7673
Revised 02/21/12