nm3clol-public/Russell_County/Building_Department/RC Mechanical Permit_202303031104023590

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document	RC Mechanical Permit 202303031104023590	../RC Mechanical Permit_202303031104023590.pdf	Russell_County Building_Department	null	application/pdf	178293	8732bf3632c02732d3abf25b26b889bcafd69a87d34cca91bd4001f939a02d73	433a6dafac869c329764ef3895de8e6c022462ca

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

Russell County Mechanical 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: Who will be considered the Applicant (Permit Holder) Property Owner Contractor:

Contractor Information

Business Name:

Contact Name:

Address: City/State: Zip Code:

State License#: Exp. Date: Phone:

Cost of Construction:

Project Description

Type Of

Work

HVAC

Gas

Generator

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 hourfor the purpose of enforcing the provisions of the applicable code(s).

Signature Printed Name: Date:

---

mailto:build@russellcountyva.us RUSSELL COUNTY BUILDING DEPARTMENT

137 Highland Dr. Suite D Lebanon, VA 2426

‘Telephone: 276-889-8012

Fax: 276-889-8009

‘build@russelleountyva.us Josh Stinson-Building Official

Russell County Mechanical Permit Application

‘Construction

‘Category: Residential Non-Residential — Thone opens | ing halos Wa ae Information Tax Map IDF Sie Imad Atos Poncay Adio io wil be consdeed he Appian (Pei olde Propny Ownet Contactor Busines Nan Contactor | Coast ame Information Res casa Tip Coe Site set Tap Date Phone

Cost oF Construction:

Project Description

Type rivac or O Work

Gas

(Generator

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 iperforms 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: Dates,

[Thereby certify that Iam 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 asa designated agent I agree to conform o all applicable state and local regulations, [rules and policies and such shall be deemed a condition entering into the exercise ofthe permit. In add 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 {enforcing the provisions ofthe applicable code(s)

‘Signature, Printed Name: Dates,

Property: 
Phone: 
Information: 
Water Source: 
Tax Map ID: 
Septic: 
Who will be considered the Applicant Permit Holder Property Owner ContractorRow1: 
Contractor Information: 
Business Name: 
Contact Name: 
Address: 
CityState: 
Zip Code: 
State License: 
Exp Date: 
Phone_2: 
Cost of Construction: 
undefined: 
Project Description: 
Description: 
Project Description_2: 
Type: 
Type Of Work: 
HVAC Gas Generator: 
Printed Name: 
Date: 
Printed Name_2: 
Date_2: 
Check Box18: Off
Check Box19: Off
Check Box27: Off
Check Box28: Off
Check Box29: Off
Check Box30: Off
Check Box31: Off