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Russell County Building Department
137 Highland Dr.
Lebanon, VA  24266
Phone: 276-889-8012
Fax:  276-889-8009
[email protected]
Josh Stinson – Building Official
Sign Permit Application
Property Owner Information
Name:
Mailing Address:
City: State: Zip Code:
911 Address: Phone: Cell:
Tax Map I.d.# Septic #: Water Source:
Directions:
Applicant Information ( If other than Property Owner)
Name:
Mailing Address:
City/State/ Zip:
Contractor – Business Name:
State License # Exp. Date Phone:
Estimated Cost of Construction:  $
Please Complete :
Size of Sign
Illuminated
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).
Applicant:      Date:
Signature
FOR COUNTY USE ONLY
Date Application Received:          Received By:
Building Permit Fee: $   Total Fee Amount:
Russell County Building Department
137 Highland Dr.
Lebanon, VA. 24266
Phone: 276-889-8012
Fax: 276-889-8009
[email protected]
Josh Stinson ~ Building Official
Sign Permit Application
Property Owner Information
Name:
Mailing Address:
Git State: Zip Code:
911 Address: Phone: Cat:
Tax Map Let Septic #: Water Source:
Directions:
Applicant Information (If other than Property Owner)
Name:
Mailing Address:
City/Statel Zip:
Contractor ~ Business Name:
Sate License [sp Dave [Phones
Estimated Cost of Construction: $
Please Complete
of Sign
Mluminated
Thereby certify that Iam the owner ofthe record of the herein described property, or that the proposed work has
been authorized by the owner of record and that I have hecn authorized to make this application as a designated
agent [agree to conform to all applicable state and local regulations, rules and policies and such shall be deemed a
‘condition entering into the exerese ofthe permit. In addition, ia permit i issued, I certify thatthe 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 ofthe applicable code(s).
Applicants Date:
Signature
FOR COUNTY USE ONLY
Date Application Received: Received By:
Building Permit Fee: S Total Fee Amow
Property Owner Information
Applicant Information ( If other than Property Owner)
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).
FOR COUNTY USE ONLY
Date Application Received:                                                      Received By: 
Building Permit Fee: $                                                      Total Fee Amount:

Name: 
Mailing Address: 
City: 
State: 
Zip Code: 
911 Address: 
Phone: 
Cell: 
Tax Map Id: 
Septic: 
Water Source: 
DirectionsRow1: 
DirectionsRow2: 
DirectionsRow3: 
Name_2: 
Mailing Address_2: 
CityState Zip: 
Contractor  Business Name: 
State License: 
Exp Date: 
Phone_2: 
Estimated Cost of Construction: 
Size of Sign: 
Illuminated: 
Applicant: 
Text1: 
Text2: 
Text3: 
Text4: 
Text5: 
Text6: 
Text7: