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4249 Johnny Cake Ridge Rd - State Fire Marshal & Pipeline Safety - Owners PermissionMINNESOTA STATE DEPARTMENT OF PUBLIC SAFETY Alcohol & Gambling Enforcement Bureau of Criminal Apprehension Capitol Security Crime Victim Services Driver & Vehicle Services Emergency Management / Emergency Response Commission State Fire Marshal / Pipeline Safety State Patrol Traffic Safety State Fire Marshal and Pipeline Safety 444 Cedar Street * Suite 145 * Saint Paul, Minnesota 55101 -5145 Phone: 651.201.7200 * Fax: 651.215.0525 * TTY: 651.282.6555 www.dps.state.mn.us Owners Permission for Fire Marshal Inspection If DHS facilities are to be licensed in a building which the license holder does not own, Written permission .must be obtained from the owner before the State Fire Marshal will conduct an inspection of the building. This form must be completed and signed; the license holder must send this form directly to the State Fire Marshal's Office at the address shown above. (print owner's name) o.\r cA n (' . \\ \ \.e certify that I own the building located at the following address and give my permission for a Deputy State Fire Marshal to inspect the building: Address: City: x-;v , mo ose Soh cc ob E am aware that c›-v Ior Department of Human Services to provide care in my building Note: By giving this permission, a Deput inspection of your entire building:WJ th licensure, you, as the by " in Ow er, wil violations identified duri . t a -ction Owner's Signature: Address (if different fro above): 1 O� Phone Number: 6N) 1 U. , State: 'r/\ , Zip: 55\ State Fire Marshal may conduct an r or not the applicant follows through with be responsible for the correction of any Date: has applied to the ( -(32.65 g2Z/ Any questions about this form should be directed to the State Fire Marshal's Office.