HomeMy WebLinkAboutCLE202000012 Request for Confirmation of Compliance 2020-01-10Virginia Department of Social Services
REQUEST FOR COMFIRMATION OF COMPLIANCE WITH UNIFORM STATEWIDE BUILDING CODE
SECTION I (to be completed by applicant)
(Applicant's Name) • • (Applicant's telephone number or contact information)
(Applicant's Address)
ao 5v ,fD4isT
(Address of Facility)
Type of Facility
❑ Assisted living (ambulatory) ❑ Assisted living (nonambulatory)
Child day care ❑ Adult day care (ambulatory) ❑ Adult day care (nonambulatory)
❑ Other (specify)
Number of persons being cared for:
SECTION II (to be completed by local building department or other authority responsible for USBC enforcement)
Based on a review of our records and/or evaluation, the proposed use complies with the USBC.
❑ Based on a review of our records and/or evaluation, the proposed use represents a change in the application of the USBC
which needs to be addressed with the Building Department before a determination of compliance can be made.
Use Group Classification (if known)
Date: Signature of official: ^
Name of official (printed):��
Telephone number or contact information for official: