Final Application for Electric, Plumbing and/or Mechanical Permit

County of Appomattox

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

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

inspections@appomattoxcountyva.gov
Application for Electric, Plumbing and/or Mechanical Permit

*This permit does not include any construction work
Attach Plan here

Browse Files

Cancelof
Check Appropriate Box:

ELECTRICMECHANICALPLUMBING
Description of Job
Estimated cost of total job
Owner Information
Owner(s)
Phone #:
Phone #

Area CodePhone Number
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 of Applicant will be able to receive the original Certificate of Occupancy at projects completion.
Phone #:
Applicant Phone:

Area CodePhone Number
Subdivision Name (if applicable):
Lot #
Directions
Contractor Information
Electrical Contractor:
Electrical Contractor Address:
Electrical Contractor Phone:
Contractor License #
Power Company (please select one):

Central Virginia Electric Company (CVEC)Southside Electric Company (SEC)Dominion
Plumbing Contractor:
Plumbing Contractor Address:
Plumbing Contractor Phone:
Plumbing Contractor License #:
MECH/HVAC Contractor:
MECH/HVAC Contractor Address:
MECH/HVAC Contractor Phone:
MECH/HVAC Contractor License #:
Office Use Only
BP:
Fee:
Type:
2% LEVY
USE GROUP
TOTAL
DODGE
Approved By

Clear
REQUEST FOR ELECTRIC SERVICE
The purpose(s) of electric service will be used for the following

WellAccessory StructureDwellingRecreational Vehicle
Before a permit is issued, you may need to seek additional information from the Appomattox County Health Department for approval. A 911 address will not be assigned for Wells, Accessory Structures, Recreational Vehicles or Temporary Housing.
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
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 Electric, Plumbing and/or Mechanical Permit

Owner Information

Contractor Information

Office Use Only

REQUEST FOR ELECTRIC SERVICE

OWNERS AFFIDAVIT

CERTIFICATION