forked from nm3clol/nm3clol-public
185 lines
4.8 KiB
Markdown
185 lines
4.8 KiB
Markdown
---
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type: document
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title: RC Fire Safety Permit Application 202211020910188444
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file: ../RC Fire Safety Permit Application_202211020910188444.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: 153656
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sha256sum: 8cbfd3b8003b118f6d1e13943bd1756a7d7baedfcd15918f1d3608032deacb05
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sha1sum: e7421812f3c22ec5f26c965e81cf2bb5b59fa350
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---
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RUSSELL COUNTY BUILDING
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DEPARTMENT
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137 Highland Dr. Ste. D
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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 Fire Safety Permit Application
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Construction
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Category
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Residential Non-Residential
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Property
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Owner
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Information
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Name: Phone:
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Mailing Address: Water Source:
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Tax Map I.D# Septic#
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Email Address: Property Address:
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Contractor
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Information
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Business Name:
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Contact Name:
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Address: City/State: Zip Code:
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State License#: Exp. Date: Phone:
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Cost of Construction:
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Project
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Description
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Type
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Of
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Work
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Owner 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 aware that anyone who
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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
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for those working on my project; and that I am not subject to licensure as a contractor or subcontractor for this project.
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Signature: ________________________________________________Printed Name:_______________________________________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 of
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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,
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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
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official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hour for the purpose of
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enforcing the provisions of the applicable code(s).
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Signature________________________________________________Printed Name:________________________________________Date:____________
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Fire Alarm ______
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Hood Suppression ______
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Fire Sprinkler ______
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mailto:build@russellcountyva.us
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RUSSELL COUNTY BUILDING
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DEPARTMENT
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197 Highland Dr. Ste. D
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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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uild@ russelicountyv:
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Josh Stinson—Building Official
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Russell County Fire Safety Permit Application
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Construction | Residential ‘Non-Residential
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Category
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‘Name Phone:
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rOneet [ Maling Address ‘Water Source:
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Information
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Tax Map LDF
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[Email Address: Propenty Address
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Business Name:
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Contractor [Contact Name
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Information
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Address: GiiyiState: Zip Code:
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‘Siate License® Exp. Date Phone:
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‘Cost of Construction
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Project
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Description,
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Type
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or Fire Alarm
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Work
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Hood Suppression
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Fire Sprinkler
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wner Statement
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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
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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
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for those working on my project; and that I am not subject to licensure as a contractor or subcontractor for this project.
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ignaturs
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Printed Name: Date:
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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
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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,
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[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
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ficial or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of
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snforcing the provisions of the applicable code(s).
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signature Printed Name: Da
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undefined:
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undefined_2:
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Residential NonResidential:
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Category:
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Name:
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Phone:
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Mailing Address:
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Water Source:
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Tax Map ID:
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Septic:
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Email Address Property AddressRow1:
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Contractor Information:
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Business Name:
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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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State License:
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Exp Date:
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Phone_2:
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Cost of Construction:
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undefined_3:
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Project Description:
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Project Description_2:
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Project Description_3:
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Type:
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Type Of Work:
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Fire Alarm Hood Suppression Fire Sprinkler:
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undefined_4:
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Hood Suppression:
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Fire Sprinkler:
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Printed Name:
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Date:
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Printed Name_2:
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Date_2:
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