nm3clol-public/Russell_County/Building_Department/RC Plumbing Permit Application

type	title	file	tags	docDate	contentType	contentLength	sha256sum	sha1sum
document	RC Plumbing Permit Application	../RC Plumbing Permit Application.pdf	Russell_County Building_Department	null	application/pdf	156921	2f3f8f95352d83409a8b1eb0e88bfa5baa5da73da04dfa2625520320ad019165	2e1c07d07f768179110fe5454c657fef678c101d

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 Plumbing 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:

Potable Water _______

Waste Water ________

New ______

Repair _______

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

Russell County Plumbing Permit Application

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‘Cost of Construction:

Project Description,

Type or Potable Water Work New

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Waste Water Repair

ywner 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.

‘ignature: Printed Name: Date:

{Thereby certify that Tam the owner of the record of the herein described property, or that the proposed work has been authorized by the owner of ‘ecord 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 ficial or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of

anforcing the provisions of the applicable code(s).

Signature

ited Name: Date:

Category: 
Name: 
Phone: 
Mailing Address: 
Water Source: 
Tax Map ID: 
Septic: 
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: 
Printed Name: 
Date: 
Printed Name_2: 
Date_2: 
Check Box1: Off
Check Box2: Off
Text3: 
Text4: 
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box8: Off
Signature: