STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
LOCAL FIRE INSPECTION AUTHORITY INFORMATION
REQUIRED BY THE DEPARTMENT OF
SOCIAL SERVICES, COMMUNITY CARE LICENSING
DIVISION
DATE:
APPLICANT NAME:
FACILITY NAME:
FACILITY ADDRESS:
As part of the application process, the licensing agency is responsible for obtaining a fire safety
inspection from the local fire inspection authority having jurisdiction in the area where your facility is
located.
To help us expedite this process, we are requiring that you identify the local fire inspection authority that
is responsible to inspect your facility and issue a fire clearance.
LOCAL FIRE INSPECTION AUTHORITY:
ADDRESS:
CITY AND ZIP CODE:
PLEASE RETURN THIS FORM WITH YOUR COMPLETED APPLICATION
LIC 9054 (3/99)