Request For Fire Safety Inspection
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1Minnesota State Fire Marshal Division
REQUEST FOR FIRE SAFETY INSPECTION
State Fire Marshal Office
Local Fire Inspector
(Must be on approved list)
445 Minnesota Street, Suite 145
____________________________
Name: _
St Paul, MN 55101-5145
(651) 201-7200
_______________________
Date Requested:
APPLICANT’S NAME
APPLICANT’S E-MAIL
ADDRESS
CITY
ZIP CODE
COUNTY
TELEPHONE #
CELL PHONE
REQUESTING AGENCY
REQUESTOR’S NAME
REQUESTOR’S PHONE
REQUESTOR’S E-MAIL
Proposed Use:
Family Child Care for ______ children
Family Adult Day Services (R-3 inspection required)
Group Child Care for ______ children
Adult Day Care for ______ adults
Child Foster Care for ______ persons
Day Training Facility for ______ adults
Adult Foster Care for ______ persons
Chemical Dependency Program Facility
Existing use:
Areas to be used:
NOTE: For RENTAL property, a
Single family residence
Basement
signed permission form by the
Multiple Dwelling
First Floor
Landlord/ Owner to allow inspection
Apartment (3 or more units)
Second Floor
of the entire building must
Duplex
Third Floor or above
accompany this request before
Townhouse
inspection will be conducted.
Reason for request:
Mobile Home
Mixed occupancy building (i.e., Attached Garage)
Wood Burning Appliance
Multiple Dwelling (i.e., apartment, townhome, duplex)
Care in Basement
Required Per Rule or Statue
Reasonable cause
(explain in comments)
Comments _________________________________________________________________________________________
_______________________________________________________________
Received stamp
$50.00 Fee Required per MN Statue
_______________________________________________________________
For State Fire Marshal Division Use:
Fee Paid
Agency Check
File #: ______________________________
ID #: ______________________________
Money Order
Scanned: _________________________
Assigned to: ____________________________
Cert. Bank Check
Form 1-22-2013
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