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RUSSELL COUNTY BUILDING
DEPARTMENT
137 Highland Dr. Suite D
Lebanon, VA 2426
Telephone: 276-889-8012
Fax: 276-889-8009
[email protected]
Josh Stinson—Building Official
Date:
Russell County Electrical 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 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
New Service Additional Wiring Repair Service Reconnect Upgrade
Appalachian Power:
Old Dominion:
AMPS
Overhead Service
Underground Service
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:
Is the power currently disconnected
Yes No
If yes, How long disconnected? ________

mailto:[email protected]
RUSSELL COUNTY BUILDING
DEPARTMENT
187 Highland Dr. Suite D
Lebanon, VA 2426
‘Telephone: 276-889-8012
Fax: 276-889-8009
build@russellcount
Josh Stinson—Building Official
Date:
Russell County Electrical Permit Application
‘Construction
corsrvetion | ident [_] Non-Residential
‘Name Phone:
Property Nailing Address Water Sours
Information
Tax Map LD? Septic?
[Email Address Property Adres
lho wil be considered the permit hoKder Property owner Contractor:
Business Name:
Contractor | Contact Name:
Information
ales GigiState Zip Cove
Slate License Exp. Date Phone:
Cost of Consiacton
Project
Description
“Or Additional Wi Repair S R Upgrade
Of |New Service tional Wiring epair Service econnect
werk O O O O O
Appalachian Power: O Overhead Service [ ] Is the power currently disconnected
No
Old Dominion: ~— [_] Underground Service [ ‘Yes im
If yes, How long disconnected?
AMPS
(Owner Statement
My signature below confirms that Iam familiar withthe Code of Virginia Title 4.1-1111 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 fo licensure as a contractor or subcontractor for this project.
‘Signature: Printed Name: Date:
IThereby certify that 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 ad ‘a permit is issued, I certify that the
-ode official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of
forcing the provisions of the applicable code(s).
‘Signature, Printed Name: Dates,
Residential NonResidential: 
undefined: Off
undefined_2: Off
Name: 
Phone: 
Mailing Address: 
Water Source: 
Tax Map ID: 
Septic: 
Contractor Information: 
Business Name: 
Contact Name: 
Address: 
CityState: 
Zip Code: 
State License: 
Exp Date: 
Phone_2: 
Cost of Construction: 
Project Description: 
Description: 
Project Description_2: 
Upgrade: 
Repair Service: 
Reconnect: 
Additional Wiring: Off
Appalachian Power Old Dominion  AMPS Overhead Service Underground ServiceRow1: 
Printed Name: 
Date: 
Printed Name_2: 
Date_2: 
Check Box1: Off
Check Box2: Off
Check Box3: Off
Check Box4: Off
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box8: Off