---
type: document
title: RC Certificate of Occupancy Permit Application Form 2
file: ../RC Certificate of Occupancy Permit Application Form_2.pdf
tags:
  - Russell_County
  - Building_Department
docDate: null
contentType: application/pdf
contentLength: 126202
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sha1sum: fbbc2a484a7337672b7c65be7c6a252bdbec712f
---

Russell County Building Department 
137 Highland Dr. Ste D. 

Lebanon, VA  24266 
Phone: 276-889-8012 
    Fax:  276-889-8009 

build@russellcountyva.us 
Josh Stinson– Building Official 

Certificate of Occupancy 
 Application 

 

PROPERTY OWNER INFORMATION 

Name: 

Mailing Address: 

City:  State:  Zip Code:  

Phone Cell:  

Tax Map I.d.# Septic #: Water Source: 

E-911 Address:  Use Group:   

Date of Construction: # of Occupants # of Bedrooms 

Directions:  

 

 

 

 

Building Use:  Reason for Permit: 

CONSTRUCTION CATEGORY 

Residential Commercial  

 

No. of Amps Appalachian Power  Old Dominion  

   

 

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). 
 
Applicant:                                                                                                                  Date: 

 

FOR OFFICE USE ONLY 

Date Application Received:                                                      Received By:  

Building Permit Fee: $                                                      Total Fee Amount: 

 

 

Russell County Building Department
137 Highland Dr. Ste D.
Lebanon, VA. 24266
Phone: 276-889-8012
Fax: 276-889-8009
build@russellcountyva.us
Josh Stinson~ Building Official

Certificate of Occupancy
Application

PROPERTY OWNER INFO!

10N

Name:

ailing Address:

Zip Code:
Phone

Tax Map Let Septie #: Water Sou
E911 Address: Use Group:

Date of Construction: ¥ of Occupants # of Bedrooms
Directions:

Building Use: Reason for Permit

Residential o ‘Commercial g

No. of Amps Appalachian Power ia Old Dominion []

1 hereby certify that 1am the owner ofthe record of the herein described property, oF that the proposed work has been authorized by the owner of
record and that [have been authorized to make tl 1 designated agent I agrce to conform to all applicable state and local regulations,
rules and policies and such shall be deemed 1 condi io the exercise ofthe permit. In addition, ifa 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).

Applicant: Date:

FOR OFFICE USE ONLY

Date Application Received: Received By:

Building Permit Fee: $ Total Fee Amount:




	PROPERTY OWNER INFORMATION
	CONSTRUCTION CATEGORY
	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).
	FOR OFFICE USE ONLY
	Date Application Received:                                                      Received By: 
	Building Permit Fee: $                                                      Total Fee Amount:

	Application: 
	Name: 
	Mailing Address: 
	City: 
	State: 
	Phone: 
	Zip CodeCell: 
	Tax Map Id: 
	Septic: 
	E911 Address: 
	Water SourceUse Group: 
	Date of Construction: 
	 of Occupants: 
	 of Bedrooms: 
	DirectionsRow1: 
	DirectionsRow2: 
	DirectionsRow3: 
	DirectionsRow4: 
	Building Use: 
	Reason for Permit: 
	CONSTRUCTION CATEGORY: 
	Residential: 
	Commercial: 
	undefined: 
	undefined_2: 
	Commercial_2: 
	undefined_3: 
	Old Dominion: Off
	No of AmpsRow1: 
	Appalachian PowerRow1: 
	Old DominionRow1: 
	Applicant: 
	FOR OFFICE USE ONLY: 
	Date Application Received Received By: 
	Building Permit Fee  Total Fee Amount: