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RUSSELL COUNTY BUILDING
DEPARTMENT
137 Highland Dr. Ste. D
Lebanon, VA 2426
Telephone: 276-889-8012
Fax: 276-889-8009
[email protected]
Josh Stinson—Building Official
Russell County Fire Safety  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:
Fire Alarm           ______
Hood Suppression       ______
Fire Sprinkler           ______
mailto:[email protected]
RUSSELL COUNTY BUILDING
DEPARTMENT
197 Highland Dr. Ste. D
Lebanon, VA 2426
‘Telephone: 276-889-8012
Fax: 276-889-8009
uild@ russelicountyv:
Josh Stinson—Building Official
Russell County Fire Safety Permit Application
Construction | Residential ‘Non-Residential
Category
‘Name Phone:
rOneet [ Maling Address ‘Water Source:
Information
Tax Map LDF
[Email Address: Propenty Address
Business Name:
Contractor [Contact Name
Information
Address: GiiyiState: Zip Code:
‘Siate License® Exp. Date Phone:
‘Cost of Construction
Project
Description,
Type
or Fire Alarm
Work
Hood Suppression
Fire Sprinkler
wner Statement
My signature below confirms that I am familiar with the Code of Virginia, Title $4.1-1111 which regulates contractors; I am aware that anyone who
jperforms 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.
ignaturs
Printed Name: Date:
IThereby 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
Irecord 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 cod
ficial or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of
snforcing the provisions of the applicable code(s).
signature Printed Name: Da
undefined: 
undefined_2: 
Residential NonResidential: 
Category: 
Name: 
Phone: 
Mailing Address: 
Water Source: 
Tax Map ID: 
Septic: 
Email Address Property AddressRow1: 
Contractor Information: 
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: 
Type Of Work: 
Fire Alarm Hood Suppression Fire Sprinkler: 
undefined_4: 
Hood Suppression: 
Fire Sprinkler: 
Printed Name: 
Date: 
Printed Name_2: 
Date_2: