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.