---
type: document
title: RC Fire Safety Permit Application 202211020910188444
file: ../RC Fire Safety Permit Application_202211020910188444.pdf
tags:
  - Russell_County
  - Building_Department
docDate: null
contentType: application/pdf
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sha1sum: e7421812f3c22ec5f26c965e81cf2bb5b59fa350
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RUSSELL COUNTY BUILDING 
DEPARTMENT 
137 Highland Dr. Ste. D 
Lebanon, VA 2426 
Telephone: 276-889-8012 
Fax: 276-889-8009 
build@russellcountyva.us 
Josh Stinson—Building Official 

Russell County Fire Safety  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: 

Contractor 
Information 

Business Name: 

Contact Name: 

Address: City/State: Zip Code: 

State License#: Exp. Date: Phone: 

Cost of Construction: 

Project 
Description 

Type 
 Of 

  Work 

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 hour for the purpose of 
enforcing the provisions of the applicable code(s). 

Signature________________________________________________Printed Name:________________________________________Date:____________ 

Fire Alarm           ______         

Hood Suppression       ______       

Fire Sprinkler           ______ 

mailto:build@russellcountyva.us
RUSSELL COUNTY BUILDING
DEPARTMENT

197 Highland Dr. Ste. D
Lebanon, VA 2426

‘Telephone: 276-889-8012

Fax: 276-889-8009

uild@ russelicountyv:

Josh Stinson—Building Official
Russell County Fire Safety Permit Application
Construction | Residential ‘Non-Residential
Category
‘Name Phone:
rOneet [ Maling Address ‘Water Source:
Information
Tax Map LDF
[Email Address: Propenty Address
Business Name:
Contractor [Contact Name
Information
Address: GiiyiState: Zip Code:
‘Siate License® Exp. Date Phone:

‘Cost of Construction

Project
Description,

Type
or Fire Alarm
Work

Hood Suppression

Fire Sprinkler

wner Statement

My signature below confirms that I am familiar with the Code of Virginia, Title $4.1-1111 which regulates contractors; I am aware that anyone who
jperforms 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.

ignaturs

Printed Name: Date:

IThereby 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
Irecord 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 cod

ficial or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of
snforcing the provisions of the applicable code(s).

signature Printed Name: Da




	undefined: 
	undefined_2: 
	Residential NonResidential: 
	Category: 
	Name: 
	Phone: 
	Mailing Address: 
	Water Source: 
	Tax Map ID: 
	Septic: 
	Email Address Property AddressRow1: 
	Contractor Information: 
	Business Name: 
	Contact Name: 
	Address: 
	CityState: 
	Zip Code: 
	State License: 
	Exp Date: 
	Phone_2: 
	Cost of Construction: 
	undefined_3: 
	Project Description: 
	Project Description_2: 
	Project Description_3: 
	Type: 
	Type Of Work: 
	Fire Alarm Hood Suppression Fire Sprinkler: 
	undefined_4: 
	Hood Suppression: 
	Fire Sprinkler: 
	Printed Name: 
	Date: 
	Printed Name_2: 
	Date_2: