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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 Plumbing 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:
Potable Water   _______
Waste Water   ________
New        ______
Repair    _______
mailto:[email protected]
RUSSELL COUNTY BUILDING DEPARTMENT
137 Highland Dr.
Lebanon, VA 2426
‘Telephone: 276-889-8012
Fax: 276-889-8009
srussellcountyva.us
Josh Stinson—Building Official
Russell County Plumbing Permit Application
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Property | Mailing Address: Water Source:
Owner ®
Fri Ais jay alc
‘Cost of Construction:
Project
Description,
Type
or Potable Water
Work New
oo
Waste Water Repair
ywner 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.
‘ignature: Printed Name: Date:
{Thereby certify that Tam the owner of the record of the herein described property, or that the proposed work has been authorized by the owner of
‘ecord 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
ficial or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hourfor the purpose of
anforcing the provisions of the applicable code(s).
Signature
ited Name: Date:
Category: 
Name: 
Phone: 
Mailing Address: 
Water Source: 
Tax Map ID: 
Septic: 
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: 
Printed Name: 
Date: 
Printed Name_2: 
Date_2: 
Check Box1: Off
Check Box2: Off
Text3: 
Text4: 
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box8: Off
Signature: