Building Application
Carroll County Department of Inspections
605-1 Pine Street Hillsville, Virginia 24343
Office: 276-730-3016 Fax: 276-730-3178

Requestor's Information

Permit Holders Name: *

Property Owners Name: *

Property Owners Mailing Address: *

Property Owners Phone Number: *

911 Job Site Address: *

Email Address: *

Type(s) of Permits Needed & Estimated Cost of Each Project

Permit(s) Needed: *

Building Cost:

Electrical Cost:

Plumbing Cost:

Mechanical Cost:

Fuel Gas Cost:

Permit Information: *

Commercial

Residential

Church/Fellowship

Are you in a Flood Zone? *

Yes

No

Dwelling Information: *

Miscellaneous:

Scope of Work: *

Scope of Work Cont. :

Well & Septic Information:

Water: * 🛈

Septic: * 🛈

Number of Rooms:

Bedrooms: *

Bathrooms: *

Construction Information:

Dimension/Sq. Footage *

Living Area Dimension/Sq. Footage:

Basement Dimension/Sq. Footage:

Garage Dimension/Sq. Footage:

Porch/Deck Dimension/Sq. Footage:

Electrical Information:

AEP Work Oder Number (Temporary) 9 Digit Number:

AEP Work Oder Number (Permanent) 9 Digit Number:

Mechanics’ Lien Agent: Section 43.1 of Code of Virginia:

Mechanics' Lien Name:

Mechanics' Lien Phone:

Mechanics' Lien Address:

VA State Licensed Contractor Information OR Owner VA STATECODE 54.1-1101

General Contractor/Agent:

General Contractor/Agent Phone:

General Contractor/Agent VA License #:

General Contractor/Agent Class:

General Contractor/Agent Responsible Party Signature:

Electrical Contractor/Agent:

Electrical Contractor/Agent Phone:

Electrical Contractor/Agent VA License #:

Electrical Contractor/Agent Class:

Electrical Contractor/Agent Responsible Party Signature:

Mechanical Contractor/Agent:

Mechanical Contractor/Agent Phone:

Mechanical Contractor/Agent VA License #:

Mechanical Contractor/Agent Class:

Mechanical Contractor/Agent Responsible Party Signature:

Plumbing Contractor/Agent:

Plumbing Contractor/Agent Phone:

Plumbing Contractor/Agent VA License #:

Plumbing Contractor/Agent Class:

Plumbing Contractor/Agent Responsible Party Signature:

Fuel Gas Contractor/Agent:

Fuel Gas Contractor/Agent Phone:

Fuel Gas Contractor/Agent VA License #:

Fuel Gas Contractor/Agent Class:

Fuel Gas Contractor/Agent Responsible Party Signature:

This document contains important information regarding contractor’s licensure law as defined in Title 54.1, Chapter 11, Code of Virginia.

PLEASE READ CAREFULLY BEFORE SIGNING OWNER/BUILDER STATEMENT

TITLE 54.1-1111. Any person applying to the code official or any other authority of a county, city, or town in this Commonwealth, charged with the duty of issuing building or other permits for the construction of any building, highway, sewer, or structure, or any removal, grading or improvement shall furnish prior to the issuance of the permit, either (i) satisfactory proof to such code official or authority that he is duly licensed or certified under the terms of this chapter to carry out or superintend the same, or (ii) file a written statement, supported by affidavit, that he is not subject to licensure or certification as a contractor or subcontractor pursuant to this chapter. The applicant shall also furnish satisfactory proof that the taxes or license fees required by any county, city, or town have been paid so as to be qualified to bid upon or contract for the work for which the permit has been applied.

TITLE 54.1-1101(Exemptions) - The provisions of this chapter shall not apply to: (Please check the appropriate box.)

Any person who performs or supervises the construction, removal, repair or improvement of no more than one primary residence owned by him and for his own use during any 24-month period.

Any person who performs or supervises the construction, removal, repair or improvement of a house upon his own real property as a bona fide gift to a member of his immediate family provided such member lives in the house. For purposes of this section, "immediate family" includes one's mother, father, son, daughter, brother, sister, grandchild, grandparent, mother-in-law, and father-in-law.

Any person who performs or supervises the repair or improvement of industrial or manufacturing facilities, or a commercial or a retail building for his own use.

Any person who performs or supervises the repair or improvement of residential dwelling units owned by him that are subject to the Virginia Residential Landlord and Tenant Act (§ 55-248.2, et seq.)

WARNING I hereby affirm that I have read Title 54.1-1111 Code of Virginia and fully understand the contents thereof and that I am not subject to licensure as a contractor or subcontractor. I further affirm that I will be solely responsible for all construction on the described property allowed by the permit(s) hereby issued. If the work is performed by any other person or firm employed by me, that person or firm must comply with state and local contractor licensing laws.

Applicant Signature: *

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 the 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/his authorized representative shall have authority to enter the areas herein at any responsible hour for the purpose of enforcing the provisions of the applicable code(s).