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LANDLORD’S PERSMISSION (Name) (Address) (City) (Zip) has my (our) permission to care for child(ren)and/or adults as a licensed Family Day Care Provider Child Foster Care Provider Adult Foster Care Provider in addition to their own family members. By giving this permission a Deputy State Fire Marshal or State Fire Marshal locally approved inspector may do an inspection of your entire building. You, the owner of the building, will be responsible for any corrections that are needed whether or not the applicant follows through with licensure. Landlord’s Signature Date Print Name Address Telephone Number CCSS (01-2012)