---
type: document
title: RC Plumbing Permit Application
file: ../RC Plumbing Permit Application.pdf
tags:
  - Russell_County
  - Building_Department
docDate: null
contentType: application/pdf
contentLength: 156921
sha256sum: 2f3f8f95352d83409a8b1eb0e88bfa5baa5da73da04dfa2625520320ad019165
sha1sum: 2e1c07d07f768179110fe5454c657fef678c101d
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RUSSELL COUNTY BUILDING DEPARTMENT 
137 Highland Dr. 
Lebanon, VA 2426 
Telephone: 276-889-8012 
Fax: 276-889-8009 
build@russellcountyva.us 
Josh Stinson—Building Official 

Russell County Plumbing 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:____________ 

Potable Water   _______ 

Waste Water   ________ 

New        ______   

Repair    _______ 

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

Russell County Plumbing Permit Application

CeO | pestont [] worked]
Property | Mailing Address: Water Source:
Owner ®

Fri Ais jay alc

‘Cost of Construction:

Project
Description,

Type
or Potable Water
Work New

oo

Waste Water Repair

ywner 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.

‘ignature: Printed Name: Date:

{Thereby certify that Tam the owner of the record of the herein described property, or that the proposed work has been authorized by the owner of
‘ecord 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
ficial or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of

anforcing the provisions of the applicable code(s).

Signature

ited Name: Date:




	Category: 
	Name: 
	Phone: 
	Mailing Address: 
	Water Source: 
	Tax Map ID: 
	Septic: 
	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: 
	Printed Name: 
	Date: 
	Printed Name_2: 
	Date_2: 
	Check Box1: Off
	Check Box2: Off
	Text3: 
	Text4: 
	Check Box5: Off
	Check Box6: Off
	Check Box7: Off
	Check Box8: Off
	Signature: