forked from nm3clol/nm3clol-public
254 lines
6.2 KiB
Markdown
254 lines
6.2 KiB
Markdown
---
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type: document
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title: RC Commercial Building Permit 202303031102148868
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file: ../RC Commercial Building Permit_202303031102148868.pdf
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tags:
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- Russell_County
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- Building_Department
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docDate: null
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contentType: application/pdf
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contentLength: 161892
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sha256sum: ffa4c79d5a4d47108c048de4f5f7a9fa79e8f5c1ca07671c0823cd1e24fe0b74
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sha1sum: c3a8c0e12dc9701b18a02383265c96707f724eb1
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---
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RUSSELL COUNTY BUILDING DEPARTMENT
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137 Highland Dr.
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Lebanon, VA 2426
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Telephone: 276-889-8012
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Fax: 276-889-8009
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build@russellcountyva.us
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Josh Stinson—Building Official
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Russell County Commercial Building Permit Application
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Type of
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Work New Construction Addition Alteration/Remodel Demolition
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Building Use Building Primary Use New Building Sq. ft.
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Alt.Remodel
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Information
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Year Built: Area of Alt./Remodel Asbestos Survey:
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Who will be considered the applicant?
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(Permit Holder)
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Property Owner: Contractor:
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Property
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Owner
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Name: Phone:
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Mailing Address: Email Address:
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Property
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Information
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Tax Map I.D# Septic# Water Source:
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Estimated Cost of Construction Flood Zone:
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Total Amount of Land Disturbance: Erosion & Sediment Plan
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Required: Yes No
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Contractor
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Information
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Contact Name:
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Address: City/State: Zip Code:
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VA State License#: Exp. Date: Phone:
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Project
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Description
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Site
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Location-
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Directions to
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site:
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***PLEASE COMPLETE REVERSE SIDE OF APPLICATION***
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mailto:build@russellcountyva.us
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RUSSELL COUNTY BUILDING DEPARTMENT
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137 Highland Dr.
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Lebanon, VA 2426
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‘Telephone: 276-889-8012
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Fax: 276-889-8009
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build@russellcountyva.us
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Josh Stinson—Building Official
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Russell County Commercial Building Permit Application
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Site
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Location-
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Directions to
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ite:
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Typeot
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Work New Construeton Addition, Alteration/Remodel Demolition,
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Building Use | Building Primary Use ‘New Building Sq. ft.
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‘AlgRemodel | Year Bul ‘Area of AkRemodet ‘Asbestos Suey
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Information
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‘Who willbe considered the applicant? Property Owner Contractor
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(Permit Holder)
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Nae Phone
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Property
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Owner Mailing Address: Email Address:
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Tax Map 1D Septet Water Sours:
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Property
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Information
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Estimated Cost of Construction Flood Zone:
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Total Amount of Land Disturbance: Erosion & Sediment Pan
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Reguied: Yes No
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Contact Name
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Contractor
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Information | Aadres Cyt Zip Cole
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WA State License Exp: Date Phone
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Project
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Description
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***PLEASE COMPLETE REVERSE SIDE OF APPLICATION***
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RUSSELL COUNTY BUILDING DEPARTMENT
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137 Highland Dr.
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Lebanon, VA 2426
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Telephone: 276-889-8012
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Fax: 276-889-8009
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build@russellcountyva.us
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Josh Stinson—Building Official
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PLEASE READ AND SIGN:
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Owner
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Statement
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My signature below confirms that I am familiar with the Code of Virginia, Title 54.1-1111 which regulates contractors; I am
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aware that anyone who performs work for me, is required to have a state contractor license and trade certification (if applicable);
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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
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contractor or subcontractor for this project.
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Signature: Date:
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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
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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
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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
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certify that the code official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hour
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for the purpose of enforcing the provisions of the applicable code(s).
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Signature: Date:
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FOR OFFICE USE ONLY Date Received:
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Building Permit Fee: Levy: Total Fee Amount
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mailto:build@russellcountyva.us
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RUSSELL COUNTY BUILDING DEPARTMENT
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137 Highland Dr.
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Lebanon, VA 2426
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‘Telephone: 276-889-8012
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Fax: 276-889-8009
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build@russelicountyva.
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Josh Stinson—Building Official
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DANE
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PLEAS IGN
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‘My signature below confirms that I am familiar with the Code of Virginia, Title $4.1-1111 which regulates contractors; [am
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aware that anyone who performs work for me, is required to have a state contractor license and trade certification (if applicable);
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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
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Statement | contractor or subcontractor for this project.
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‘Signature: Date:
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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
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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
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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
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certify that the code official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hour
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for the purpose of enforcing the provisions of the applicable code(s).
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Signature: Date:
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FOR OFFICE USE ONLY Date Received:
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Building Permit Fee: Levy: ‘Total Fee Amount
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Type of Work:
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New Construction:
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Addition:
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AlterationRemodel:
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Demolition:
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Building Use:
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Building Primary Use:
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New Building Sq ft:
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Year Built:
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Area of AltRemodel:
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Asbestos Survey:
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AltRemodel InformationRow1:
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Property Owner:
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Contractor:
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Property Owner_2:
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Name:
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Phone:
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Mailing Address:
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Email Address:
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Property Information:
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Tax Map ID:
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Septic:
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Water Source:
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Estimated Cost of Construction:
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Flood Zone:
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Total Amount of Land Disturbance:
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Contractor Information:
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Contact Name:
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Address:
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CityState:
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Zip Code:
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VA State License:
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Exp Date:
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Phone_2:
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Project Description:
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Project Description_2:
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Project Description_3:
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Project Description_4:
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undefined:
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Site Location Directions to site:
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Site Location Directions to site_2:
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Site Location Directions to site_3:
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Site Location Directions to site_4:
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PLEASE READ AND SIGN:
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Owner Statement:
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Signature:
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Date:
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Signature_2:
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Date_2:
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FOR OFFICE USE ONLY Date Received:
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Building Permit Fee Levy Total Fee Amount:
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Check Box1: Off
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Check Box2: Off
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