4555 Erin Dr - Interagency Inspection Form 2019-05-23 -License-Number.- 1079291-
0►EPARTMENT OF INTERAGENCY REQUEST FOR BUILDING INSPECTION
HUMAN SERVICES
Ta: Building Inspector - City of Eagan Date: 6/15/19
from:-P-eula-Halverson• done-Number: 651-431-5653-
E1New Program ri Change in ownership ZOther New address
Prior to issuing a license/certification, verificationis required that:a facility.is in compliance with
appropriate state,county,andJocel- ilrng c odes.•PJease complete this-form and return t'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 and address of facility: River Ridge LLC Outpatient Cliff Place, 4555 Erin Dr, Suite 200, Eagan, MN 55122
Proposed use: To provide substance use disorder treatment services.
Program contact person: Brian Samrnon Phone number 952-564-3000 or briansammon@ooptionsminnesota.eorn
Area of facility to be used: Unknown at this time.
Numbers and age ranges of participants: Serving males & females ages 18 - 99 years old.
Does the facility plan to serve handicapped.individuals? Unknown
ui ina nspec'tion' exults:
.▪ NotApplicable:.facility-located_in-non coded.area_.
Date of referendum vote removing code requirements:
Signature and Title of Local Official:
An inspection is required for all proposed.facilities located in a coda area which involves new construction,
major renovation,change in occupancy, or any facility not currently being used for proposed usage.
❑ Fecifity-meets-building-code-requirements.
❑ Proposed change is not a change in occupancy. [Enclose copy of original Certificate of Occupancy.]
❑ Facility,does'not meet requirements and•oannot be occupied until orders ere met. [Enclose copy cf
orders issued:]
X.Facility,does-not meet-requirements;-but-may temporarily be.occupied until: //t ]'1 (date),
pending completion of orders.
Signature of Building inspector: cie�1� (C05-1.) 75(a :� , Phone Number.
Agency Name: C// effv /A/SPF-4-7-70,V L t,71 , Date: 37,23hr
When inspection is complete, mail, email,or fax this form and any additional orders to:,
-Minnesota-Department-of-Human-Services,-Division-of-Licensing-
iP:rO.Box 12 s ,. 1 d1 '
oiiti
St.Paul,MN 55164-0242
Fax Number: 651-431-7673
"Mentailaealt'h7-Chem1C rpopendoncy eman. elbsatibcOncenSingettate.mmtra Revised 02/21/12