DSD 11 (07/01/2011)
BUSINESS PHONE NUMBER
PERMIT APPLICANT INFORMATION
APPLICANT FOR PERMIT/BUSINESS NAME
BUSINESS STREET ADDRESS (P.O. box unacceptable) CITY STATE
ZIP CODE
BUSINESS OWNER/AGENT NAME BUSINESS PHONE NUMBER
APPLICANT LICENSEE NUMBER
BUSINESS JURISDICTION
Purpose: Vehicle demolishers use this form to apply for a 15-day permit to allow the operation of demolisher equipment at a site other than the
location specified on the demolisher license.
Instructions: A permit costs $15 and only one permit is issued per application. A separate application must be completed for each mobile operation
site desired. A new application must be submitted when a 15-day permit expires and you wish to continue operations at the site
specified on the permit. Fax completed application(s) to (804) 367-7046, or mail completed form(s) and application fee(s) to Dealer
Services at the above address.
MOBILE OPERATION SITE INFORMATION
STATE
ZIP CODE
CITY COUNTY OF
I certify that I hold a valid Virginia salvage and/or demolisher's license and I further certify and affirm that all information presented in this form is true and
correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I
make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a
criminal violation.
DATE(mm/dd/yyyy)
BUSINESS OWNER/AGENT NAME BUSINESS OWNER/AGENT SIGNATURE
MOBILE OPERATION STREET ADDRESS
MOBILE OPERATION START DATE (mm/dd/yyyy)
BUSINESS JURISDICTION
CITY
APPLICATION
MOBILE DEMOLISHER PERMIT OF OPERATION
CITY COUNTY OF
DEMOLISHER BUSINESS NAME TRADING AS NAME
BUSINESS OWNER/AGENT NAME DEMOLISHER LICENSEE NUMBER
TRADING AS NAME
MOBILE OPERATION END DATE (mm/dd/yyyy - not to exceed 15 days from start date)
DEMOLISHER INFORMATION (If not the permit applicant shown above)
PERMIT APPLICANT CERTIFICATION
