--- type: document title: RC Commercial Building Permit 202303031102148868 file: ../RC Commercial Building Permit_202303031102148868.pdf tags: - Russell_County - Building_Department docDate: null contentType: application/pdf contentLength: 161892 sha256sum: ffa4c79d5a4d47108c048de4f5f7a9fa79e8f5c1ca07671c0823cd1e24fe0b74 sha1sum: c3a8c0e12dc9701b18a02383265c96707f724eb1 --- 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 Commercial Building Permit Application Type of Work New Construction Addition Alteration/Remodel Demolition Building Use Building Primary Use New Building Sq. ft. Alt.Remodel Information Year Built: Area of Alt./Remodel Asbestos Survey: Who will be considered the applicant? (Permit Holder) Property Owner: Contractor: Property Owner Name: Phone: Mailing Address: Email Address: Property Information Tax Map I.D# Septic# Water Source: Estimated Cost of Construction Flood Zone: Total Amount of Land Disturbance: Erosion & Sediment Plan Required: Yes No Contractor Information Contact Name: Address: City/State: Zip Code: VA State License#: Exp. Date: Phone: Project Description Site Location- Directions to site: ***PLEASE COMPLETE REVERSE SIDE OF APPLICATION*** mailto:build@russellcountyva.us 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 Commercial Building Permit Application Site Location- Directions to ite: Typeot Work New Construeton Addition, Alteration/Remodel Demolition, Building Use | Building Primary Use ‘New Building Sq. ft. ‘AlgRemodel | Year Bul ‘Area of AkRemodet ‘Asbestos Suey Information ‘Who willbe considered the applicant? Property Owner Contractor (Permit Holder) Nae Phone Property Owner Mailing Address: Email Address: Tax Map 1D Septet Water Sours: Property Information Estimated Cost of Construction Flood Zone: Total Amount of Land Disturbance: Erosion & Sediment Pan Reguied: Yes No Contact Name Contractor Information | Aadres Cyt Zip Cole WA State License Exp: Date Phone Project Description ***PLEASE COMPLETE REVERSE SIDE OF APPLICATION*** 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 PLEASE READ AND SIGN: 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: 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: Date: FOR OFFICE USE ONLY Date Received: Building Permit Fee: Levy: Total Fee Amount mailto:build@russellcountyva.us RUSSELL COUNTY BUILDING DEPARTMENT 137 Highland Dr. Lebanon, VA 2426 ‘Telephone: 276-889-8012 Fax: 276-889-8009 build@russelicountyva. Josh Stinson—Building Official DANE PLEAS IGN ‘My signature below confirms that I am familiar with the Code of Virginia, Title $4.1-1111 which regulates contractors; [am aware that anyone who performs work for me, is required to have a state contractor license and trade certification (if applicable); Owner | 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 Statement | contractor or subcontractor for this project. ‘Signature: Date: Thereby certify that Tam the owner of the record of the herein described property, oF 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: Date: FOR OFFICE USE ONLY Date Received: Building Permit Fee: Levy: ‘Total Fee Amount Type of Work: New Construction: Addition: AlterationRemodel: Demolition: Building Use: Building Primary Use: New Building Sq ft: Year Built: Area of AltRemodel: Asbestos Survey: AltRemodel InformationRow1: Property Owner: Contractor: Property Owner_2: Name: Phone: Mailing Address: Email Address: Property Information: Tax Map ID: Septic: Water Source: Estimated Cost of Construction: Flood Zone: Total Amount of Land Disturbance: Contractor Information: Contact Name: Address: CityState: Zip Code: VA State License: Exp Date: Phone_2: Project Description: Project Description_2: Project Description_3: Project Description_4: undefined: Site Location Directions to site: Site Location Directions to site_2: Site Location Directions to site_3: Site Location Directions to site_4: PLEASE READ AND SIGN: Owner Statement: Signature: Date: Signature_2: Date_2: FOR OFFICE USE ONLY Date Received: Building Permit Fee Levy Total Fee Amount: Check Box1: Off Check Box2: Off