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Russell County Building Department
137 Highland Dr. Ste D.
Lebanon, VA  24266
Phone: 276-889-8012
Fax:  276-889-8009
[email protected]
Josh Stinson– Building Official
Certificate of Occupancy
Application
PROPERTY OWNER INFORMATION
Name:
Mailing Address:
City:  State:  Zip Code:
Phone Cell:
Tax Map I.d.# Septic #: Water Source:
E-911 Address:  Use Group:
Date of Construction: # of Occupants # of Bedrooms
Directions:
Building Use:  Reason for Permit:
CONSTRUCTION CATEGORY
Residential Commercial
No. of Amps Appalachian Power  Old Dominion
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).
Applicant:                                                                                                                  Date:
FOR OFFICE USE ONLY
Date Application Received:                                                      Received By:
Building Permit Fee: $                                                      Total Fee Amount:
Russell County Building Department
137 Highland Dr. Ste D.
Lebanon, VA. 24266
Phone: 276-889-8012
Fax: 276-889-8009
[email protected]
Josh Stinson~ Building Official
Certificate of Occupancy
Application
PROPERTY OWNER INFO!
10N
Name:
ailing Address:
Zip Code:
Phone
Tax Map Let Septie #: Water Sou
E911 Address: Use Group:
Date of Construction: ¥ of Occupants # of Bedrooms
Directions:
Building Use: Reason for Permit
Residential o ‘Commercial g
No. of Amps Appalachian Power ia Old Dominion []
1 hereby certify that 1am the owner ofthe record of the herein described property, oF that the proposed work has been authorized by the owner of
record and that [have been authorized to make tl 1 designated agent I agrce to conform to all applicable state and local regulations,
rules and policies and such shall be deemed 1 condi io the exercise ofthe permit. In addition, ifa 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).
Applicant: Date:
FOR OFFICE USE ONLY
Date Application Received: Received By:
Building Permit Fee: $ Total Fee Amount:
PROPERTY OWNER INFORMATION
CONSTRUCTION CATEGORY
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).
FOR OFFICE USE ONLY
Date Application Received:                                                      Received By: 
Building Permit Fee: $                                                      Total Fee Amount:

Application: 
Name: 
Mailing Address: 
City: 
State: 
Phone: 
Zip CodeCell: 
Tax Map Id: 
Septic: 
E911 Address: 
Water SourceUse Group: 
Date of Construction: 
 of Occupants: 
 of Bedrooms: 
DirectionsRow1: 
DirectionsRow2: 
DirectionsRow3: 
DirectionsRow4: 
Building Use: 
Reason for Permit: 
CONSTRUCTION CATEGORY: 
Residential: 
Commercial: 
undefined: 
undefined_2: 
Commercial_2: 
undefined_3: 
Old Dominion: Off
No of AmpsRow1: 
Appalachian PowerRow1: 
Old DominionRow1: 
Applicant: 
FOR OFFICE USE ONLY: 
Date Application Received Received By: 
Building Permit Fee  Total Fee Amount: