G:\BUILDING REGS\Forms - Masters\Applications\2016-2017 Updated Forms\Daycare Application.doc Effective 1/18/2017
1. SITE INFORMATION:
Street Address ____________________________________________________
City/State/Zip ______________________________________________________
Jurisdiction (City, Village, or Township project is in) ________________________
Daycare Center Type A Home Type B (CCDJFS)
Name of Center/Type A Home ________________________________________
2. OWNER INFORMATION
Owner name ______________________________________________________
Address _________________________________________________________
City, State, Zip Code ________________________________________________
Phone ____________________________ Fax* _________________________
E-Mail * _________________________________________________________
3. EXISTING FACILITY TYPE
Single Family Residence (Type A) Multifamily Residence
School Church Business
Other _____________________________________________
Floors Used – Check all that apply
Story Below Grade 1
st
Floor Second Floor or more
other (describe below)
Copy of existing Certificate of Occupancy submitted with this
Application?
yes no
4. FACILITY INFORMATION
Total square feet of building _______________________
Square feet of space used for Daycare _______________
Is this facility handicap accessible? yes no
Floor plan submitted? yes no
Are rooms located on the level of exit discharge yes no some
Do rooms have exits directly to the outside? yes no some
Are restrooms provided? yes no
Does facility have a kitchen? yes no
Does facility have fire alarms? yes no
Does facility have a sprinkler system? yes no
5. NUMBER OF CHILDERN
Number of Children < 30 months of age ____________
Number of Children > 30 months of age _____________
County Community & Economic Development
3130 E. Main Street, Suite 1A, Springfield, OH 45505
(937) 521-2160/(937) 328-2621 Fax
Application Number
__________________________
(clerical only)
6. OPERATIONAL CONSTRAINTS
Days of Operation________________________________________________
Time of Operation ________________________________________________
Seasonal Operation? (school year, fall only etc) yes no
Food service? yes no
7. FIRE INSPECTION
Fire Department Inspection Completed? yes no
Fire department must inspect the facility in conjunction with this department or
a written fire inspection report from the fire department having jurisdiction must
be submitted before a certificate of occupancy will be issued and Ohio Daycare
Inspection Report completed.
8. APPLICANT INFORMATION:
Contact Person ____________________________________________________
Company Name ___________________________________________________
Address _________________________________________________________
City, State, Zip Code _______________________________________________
Phone ____________________________ Fax* _________________________
E-Mail * _________________________________________________________
I hereby certify that I am the Owner of Record, or that the proposed work is
authorized by the Owner of Record, that I have been authorized by the Owner
to make this application as his Agent, and that we agree to conform to ALL
laws of the County and the State, and that all information on this application is
truthful to the best of my knowledge. I also understand that UPFRONT FEES
ARE NON-REFUNDABLE AND NON-TRANSFERABLE.
Applicant Signature _____________________________
Date________________
Office Use Only
Intake person _______________________________
Amount Paid Upfront $_______________________
Date of Inspection Requested ___/____/____
Notified applicant of approval____/____/____ By:_______________
BUILDING OFFICIAL USE
Balance Due $________________________
Certificate and Inspection Report Approved ___/____/____
Approved by: ________________________________________
DAYCARE INSPECTION REQUEST
APPLICATION
