nm3clol-public/Russell_County/Building_Department/RC Fire Safety Permit Application_202211020910188444

type	title	file	tags	docDate	contentType	contentLength	sha256sum	sha1sum
document	RC Fire Safety Permit Application 202211020910188444	../RC Fire Safety Permit Application_202211020910188444.pdf	Russell_County Building_Department	null	application/pdf	153656	8cbfd3b8003b118f6d1e13943bd1756a7d7baedfcd15918f1d3608032deacb05	e7421812f3c22ec5f26c965e81cf2bb5b59fa350

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

Russell County Fire Safety 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:

Fire Alarm ______

Hood Suppression ______

Fire Sprinkler ______

mailto:build@russellcountyva.us RUSSELL COUNTY BUILDING DEPARTMENT

197 Highland Dr. Ste. D Lebanon, VA 2426

‘Telephone: 276-889-8012

Fax: 276-889-8009

uild@ russelicountyv:

Josh Stinson—Building Official Russell County Fire Safety Permit Application Construction | Residential ‘Non-Residential Category ‘Name Phone: rOneet [ Maling Address ‘Water Source: Information Tax Map LDF [Email Address: Propenty Address Business Name: Contractor [Contact Name Information Address: GiiyiState: Zip Code: ‘Siate License® Exp. Date Phone:

‘Cost of Construction

Project Description,

Type or Fire Alarm Work

Hood Suppression

Fire Sprinkler

wner Statement

My signature below confirms that I am familiar with the Code of Virginia, Title $4.1-1111 which regulates contractors; I am aware that anyone who jperforms 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.

ignaturs

Printed Name: Date:

IThereby 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 Irecord 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 cod

ficial or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of snforcing the provisions of the applicable code(s).

signature Printed Name: Da

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Residential NonResidential: 
Category: 
Name: 
Phone: 
Mailing Address: 
Water Source: 
Tax Map ID: 
Septic: 
Email Address Property AddressRow1: 
Contractor Information: 
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: 
Type Of Work: 
Fire Alarm Hood Suppression Fire Sprinkler: 
undefined_4: 
Hood Suppression: 
Fire Sprinkler: 
Printed Name: 
Date: 
Printed Name_2: 
Date_2: