---
type: document
title: RC Electrical Permit 202303031104560282
file: ../RC Electrical Permit_202303031104560282.pdf
tags:
  - Russell_County
  - Building_Department
docDate: null
contentType: application/pdf
contentLength: 195190
sha256sum: 0f7668ce1d37db752518e62f99e387e6d3acd25b45333df265cf2e963d0ccfe7
sha1sum: dac4f700f6a1594129e350f65bff3fb03926dc9f
---

RUSSELL COUNTY BUILDING 
DEPARTMENT 
137 Highland Dr. Suite D 
Lebanon, VA 2426 
Telephone: 276-889-8012 
Fax: 276-889-8009 
build@russellcountyva.us 
Josh Stinson—Building Official 

Date: 

Russell County Electrical Permit Application 
Construction 
Category Residential Non-Residential 

Property 
Owner 

Information 

Name: Phone: 

Mailing Address: Water Source: 

Tax Map I.D# Septic# 

Email Address: Property Address: 
Who will be considered the permit holder:   Property owner    Contractor: 

Contractor 
Information 

Business Name: 

Contact Name: 

Address: City/State: Zip Code: 

State License#: Exp. Date: Phone: 

Cost of Construction: 

Project 
Description 

Type 
Of 

Work 
New Service Additional Wiring Repair Service Reconnect Upgrade 

Appalachian Power: 

Old Dominion: 

# AMPS 

Overhead Service 

Underground Service 

Owner Statement 
My signature below confirms that I am familiar with the Code of Virginia, Title 54.1-1111 which regulates contractors; I am aware that anyone who 
performs work for me, is required to have a state contractor license and trade certification (if applicable);that I may be subject to with-holding taxes 
for those working on my project; and that I am not subject to licensure as a contractor or subcontractor for this project. 

Signature: Printed Name: Date: 

I hereby certify that I am the owner of the record of the herein described property, or that the proposed work has been authorized by the owner of 
record and that I have been authorized to make this application as a designated agent I agree to conform to all applicable state and local regulations, 
rules and policies and such shall be deemed a condition entering into the exercise of the permit. In addition, if a permit is issued, I certify that the 
code official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of 
enforcing the provisions of the applicable code(s). 

Signature Printed Name: Date: 

Is the power currently disconnected

Yes No

If yes, How long disconnected? ________
___________

mailto:build@russellcountyva.us
RUSSELL COUNTY BUILDING
DEPARTMENT

187 Highland Dr. Suite D
Lebanon, VA 2426

‘Telephone: 276-889-8012

Fax: 276-889-8009
build@russellcount

Josh Stinson—Building Official

Date:

Russell County Electrical Permit Application

‘Construction
corsrvetion | ident [_] Non-Residential
‘Name Phone:
Property Nailing Address Water Sours
Information
Tax Map LD? Septic?
[Email Address Property Adres
lho wil be considered the permit hoKder Property owner Contractor:
Business Name:
Contractor | Contact Name:
Information
ales GigiState Zip Cove
Slate License Exp. Date Phone:
Cost of Consiacton
Project
Description
“Or Additional Wi Repair S R Upgrade
Of |New Service tional Wiring epair Service econnect
werk O O O O O

Appalachian Power: O Overhead Service [ ] Is the power currently disconnected
No
Old Dominion: ~— [_] Underground Service [ ‘Yes im
If yes, How long disconnected?
# AMPS
(Owner Statement
My signature below confirms that Iam familiar withthe Code of Virginia Title 4.1-1111 which regulates contractors; I am aware that anyone who

iperforms work for me, is required to have a state contractor license and trade certification (if applicable);that I may be subject to with-holding taxes
for those working on my project; and that I am not subject fo licensure as a contractor or subcontractor for this project.

‘Signature: Printed Name: Date:

IThereby certify that am the owner of the record of the herein described property, or that the proposed work has been authorized by the owner of

record and that I have been authorized to make this application as a designated agent I agree to conform to all applicable state and local regulations,

rules and policies and such shall be deemed a condition entering into the exercise of the permit. In ad ‘a permit is issued, I certify that the
-ode official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of
forcing the provisions of the applicable code(s).

‘Signature, Printed Name: Dates,





 




	Residential NonResidential: 
	undefined: Off
	undefined_2: Off
	Name: 
	Phone: 
	Mailing Address: 
	Water Source: 
	Tax Map ID: 
	Septic: 
	Contractor Information: 
	Business Name: 
	Contact Name: 
	Address: 
	CityState: 
	Zip Code: 
	State License: 
	Exp Date: 
	Phone_2: 
	Cost of Construction: 
	Project Description: 
	Description: 
	Project Description_2: 
	Upgrade: 
	Repair Service: 
	Reconnect: 
	Additional Wiring: Off
	Appalachian Power Old Dominion  AMPS Overhead Service Underground ServiceRow1: 
	Printed Name: 
	Date: 
	Printed Name_2: 
	Date_2: 
	Check Box1: Off
	Check Box2: Off
	Check Box3: Off
	Check Box4: Off
	Check Box5: Off
	Check Box6: Off
	Check Box7: Off
	Check Box8: Off