---
type: document
title: RC Mechanical Permit 202303031104023590
file: ../RC Mechanical Permit_202303031104023590.pdf
tags:
  - Russell_County
  - Building_Department
docDate: null
contentType: application/pdf
contentLength: 178293
sha256sum: 8732bf3632c02732d3abf25b26b889bcafd69a87d34cca91bd4001f939a02d73
sha1sum: 433a6dafac869c329764ef3895de8e6c022462ca
---

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 

Russell County Mechanical 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 Applicant (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 

HVAC 

Gas 

Generator 

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: 

_________ __________

mailto:build@russellcountyva.us
RUSSELL COUNTY BUILDING
DEPARTMENT

137 Highland Dr. Suite D
Lebanon, VA 2426

‘Telephone: 276-889-8012

Fax: 276-889-8009

‘build@russelleountyva.us
Josh Stinson-Building Official

Russell County Mechanical Permit Application

‘Construction

‘Category: Residential Non-Residential
— Thone
opens | ing halos Wa ae
Information
Tax Map IDF Sie
Imad Atos Poncay Adio
io wil be consdeed he Appian (Pei olde Propny Ownet Contactor
Busines Nan
Contactor | Coast ame
Information
Res casa Tip Coe
Site set Tap Date Phone

Cost oF Construction:

Project
Description

Type rivac
or O
Work

Gas

(Generator

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
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 to licensure as a contractor or subcontractor for this project.

‘Signature: Printed Name: Dates,

[Thereby certify that Iam 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 asa designated agent I agree to conform o all applicable state and local regulations,
[rules and policies and such shall be deemed a condition entering into the exercise ofthe permit. In add 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
{enforcing the provisions ofthe applicable code(s)

‘Signature, Printed Name: Dates,





 




	Property: 
	Phone: 
	Information: 
	Water Source: 
	Tax Map ID: 
	Septic: 
	Who will be considered the Applicant Permit Holder Property Owner ContractorRow1: 
	Contractor Information: 
	Business Name: 
	Contact Name: 
	Address: 
	CityState: 
	Zip Code: 
	State License: 
	Exp Date: 
	Phone_2: 
	Cost of Construction: 
	undefined: 
	Project Description: 
	Description: 
	Project Description_2: 
	Type: 
	Type Of Work: 
	HVAC Gas Generator: 
	Printed Name: 
	Date: 
	Printed Name_2: 
	Date_2: 
	Check Box18: Off
	Check Box19: Off
	Check Box27: Off
	Check Box28: Off
	Check Box29: Off
	Check Box30: Off
	Check Box31: Off