County of Appomattox

County of Appomattox

Department of Community Development
P. 0. Box 863 Appomattox, VA 24522

Phone (434)352-8183; Fax (434)352-4214

inspections@appomattoxcountyva.gov
APPLICATION FOR AN EVENT PERMIT
Check One:

AMUSEMENT DEVICESFIREWORKSTENTSOTHER
Description of Job:
OWNER INFORMATION
Owner(s):
Phone:
Address

Current Mailing Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Applicant (If different from Owner):
*NOTE: Only those listed as the Owner or Applicant will be able to receive the original Certificate of Occupancy at projects completion.
Phone#:
Subdivision Name:
(If applicable)
Lot #:
Directions:
ADDITIONAL INFORMATION
Responsible Party
Address:
Phone #:
Square Feet:
OFFICE USE ONLY
FEE:
2% Levy:
TOTAL:
ZONING:
Type:
USE GROUP:
DODGE:
Approved by:

Clear
Owners Affidavit

This portion of the form must be notarized. You may submit the form as is to Appomattox County and then stop by during business hours (8:00 a.m.-4:30 p.m. Monday-Friday) at 153 A Morton Lane Appomattox, VA to have it printed and notarized. You may also print the PDF version of this form and have it notarized then drop it by the County Administration building in the Drop Box or at the front desk during business Hours.
Certification

(All applicants must sign below)
I hereby certify that I am the owner of record of the herein described property or that the work proposed 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 this 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

Clear
Date

MonthDayYear
Date
Should be Empty:

County of Appomattox

APPLICATION FOR AN EVENT PERMIT

OWNER INFORMATION

ADDITIONAL INFORMATION

OFFICE USE ONLY

Certification