HomeMy WebLinkAboutCLE202100142 Other 2021-11-08COMMONWEALTH OF VIRGINIA
DEPARTMENT OF SOCIAL SERVICES
CONTACT WITH LOCAL ZONING ADMINISTRATOR
THE FOLLOWING INDIVIDUAL PLANS TO SUBMIT AN APPLICATION FOR A LICENSE TO
OPERATE A FAMILY DAY HOME PURSUANT TO § 63.2-100 OF THE CODE OF VIRGINIA
To Be Completed by Operator of Family Day Home
NAME OF APPLICANT
PHYSICAL ADDRESS
04
STREET OR ROUTE NO. CITY 1 STATE ZIP
APPLICANT'S TELEPHONF,,,NUMBER: 1 l�%J1 ��/� (1 2� �Ivo l
ADDRESS: &0161 tP331-I01111�-ayn I^ �(n jU/� J
THE HOME IS LOCATED IN THE OUNT OR CITY OF ►J� ► y of 16
APPLICANT IS REQUESTING A LICENSE TO CARE FOR THE FOLLOWING NUMBER OF
CHILDREN (NOT INCLUDING CHILDREN WHO RESIDE IN THE HOME): 1
To Be Completed by Local Zoning Administrator
THE ZONING ADMINISTRATOR'S SIGNATURE ON THIS FORM VERIFIES THAT THE
APPLICANT HAS INFORMED THE ZONING ADMINISTRATOR OF HIS/HER PLANS TO
APPLY FOR A LICENSE TO OPERATE A FAMILY DAY HOME AT THE ADDRESS ABOVE.
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11 lei
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Date
Telephone Number:
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For questions, please contact your Area Licensing Office (Information Attached)
032-05-0952-03-eng (07/15)