OCR Scan (approximately)

This OCR scan may contain automatically generated text as generated using Apache Tika and Tesseract. It may not be correct. No effort has been made to correct any of these scans (so far). These OCR scans are also used in the site's Search feature. Please review the Search Policy for details about the site features. The OCR scan is provided here for reference purposes. It provides searchable text when the underlying document might not. But the scan process may not always work perfectly.

RUSSELL COUNTY BUILDING DEPARTMENT
137 Highland Dr.
Lebanon, VA 2426
Telephone: 276-889-8012
Fax: 276-889-8009
[email protected]
Josh Stinson—Building Official
Russell County Commercial Building Permit Application
Type of
Work New Construction Addition Alteration/Remodel Demolition
Building Use Building Primary Use New Building Sq. ft.
Alt.Remodel
Information
Year Built: Area of Alt./Remodel Asbestos Survey:
Who will be considered the applicant?
(Permit Holder)
Property Owner: Contractor:
Property
Owner
Name: Phone:
Mailing Address: Email Address:
Property
Information
Tax Map I.D# Septic# Water Source:
Estimated Cost of Construction Flood Zone:
Total Amount of Land Disturbance: Erosion & Sediment Plan
Required: Yes No
Contractor
Information
Contact Name:
Address: City/State: Zip Code:
VA State License#: Exp. Date: Phone:
Project
Description
Site
Location-
Directions to
site:
PLEASE COMPLETE REVERSE SIDE OF APPLICATION
mailto:[email protected]
RUSSELL COUNTY BUILDING DEPARTMENT
137 Highland Dr.
Lebanon, VA 2426
‘Telephone: 276-889-8012
Fax: 276-889-8009
[email protected]
Josh Stinson—Building Official
Russell County Commercial Building Permit Application
Site
Location-
Directions to
ite:
Typeot
Work New Construeton Addition, Alteration/Remodel Demolition,
Building Use | Building Primary Use ‘New Building Sq. ft.
‘AlgRemodel | Year Bul ‘Area of AkRemodet ‘Asbestos Suey
Information
‘Who willbe considered the applicant? Property Owner Contractor
(Permit Holder)
Nae Phone
Property
Owner Mailing Address: Email Address:
Tax Map 1D Septet Water Sours:
Property
Information
Estimated Cost of Construction Flood Zone:
Total Amount of Land Disturbance: Erosion & Sediment Pan
Reguied: Yes No
Contact Name
Contractor
Information | Aadres Cyt Zip Cole
WA State License Exp: Date Phone
Project
Description
PLEASE COMPLETE REVERSE SIDE OF APPLICATION
RUSSELL COUNTY BUILDING DEPARTMENT
137 Highland Dr.
Lebanon, VA 2426
Telephone: 276-889-8012
Fax: 276-889-8009
[email protected]
Josh Stinson—Building Official
PLEASE READ AND SIGN:
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: 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: Date:
FOR OFFICE USE ONLY Date Received:
Building Permit Fee: Levy: Total Fee Amount
mailto:[email protected]
RUSSELL COUNTY BUILDING DEPARTMENT
137 Highland Dr.
Lebanon, VA 2426
‘Telephone: 276-889-8012
Fax: 276-889-8009
build@russelicountyva.
Josh Stinson—Building Official
DANE
PLEAS IGN
‘My signature below confirms that I am familiar with the Code of Virginia, Title $4.1-1111 which regulates contractors; [am
aware that anyone who performs work for me, is required to have a state contractor license and trade certification (if applicable);
Owner | 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
Statement | contractor or subcontractor for this project.
‘Signature: Date:
Thereby certify that Tam the owner of the record of the herein described property, oF 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: Date:
FOR OFFICE USE ONLY Date Received:
Building Permit Fee: Levy: ‘Total Fee Amount
Type of Work: 
New Construction: 
Addition: 
AlterationRemodel: 
Demolition: 
Building Use: 
Building Primary Use: 
New Building Sq ft: 
Year Built: 
Area of AltRemodel: 
Asbestos Survey: 
AltRemodel InformationRow1: 
Property Owner: 
Contractor: 
Property Owner_2: 
Name: 
Phone: 
Mailing Address: 
Email Address: 
Property Information: 
Tax Map ID: 
Septic: 
Water Source: 
Estimated Cost of Construction: 
Flood Zone: 
Total Amount of Land Disturbance: 
Contractor Information: 
Contact Name: 
Address: 
CityState: 
Zip Code: 
VA State License: 
Exp Date: 
Phone_2: 
Project Description: 
Project Description_2: 
Project Description_3: 
Project Description_4: 
undefined: 
Site Location Directions to site: 
Site Location Directions to site_2: 
Site Location Directions to site_3: 
Site Location Directions to site_4: 
PLEASE READ AND SIGN: 
Owner Statement: 
Signature: 
Date: 
Signature_2: 
Date_2: 
FOR OFFICE USE ONLY Date Received: 
Building Permit Fee Levy Total Fee Amount: 
Check Box1: Off
Check Box2: Off