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. Suite D
Lebanon, VA 2426
Telephone: 276-889-8012
Fax: 276-889-8009
[email protected]
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:[email protected]
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
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