APPLICANT
APPLICANT NAME (PLEASE PRINT):
REPRESENTING (NAME OF COMPANY):
APPLICANT SIGNATURE:
DATE:
OWNER AFFIDAVIT
Complete this section only if you are an OWNER doing your own work,
and are not subject to licensure as a contractor or subcontractor.
If you are an owner and intend to do the work or subcontract the work, an Owner Affidavit is required
certifying that you are the owner of this tract or parcel of land, that you have applied for this permit, and
are not subject to licensing as a contractor or subcontractor. Signing the Owner Affidavit and obtaining
the permit in your name, designates you, as the owner, responsible for the quality of the work and
compliance with applicable state and local codes. This “Owner Affidavit” must be completed, with the
signature of a person who witnessed your signature to this document, acknowledging your compliance
with Section 54.1-1111 of the Code of Virginia. (Note: Lessees are owners per state law.)
I, as the owner, will be responsible for the work performed on my property, and shall be responsible for
compliance with all state laws regulating building construction and use, and compliance with all county
ordinances.
OWNER’S SIGNATURE: DATE: PLEASE PRINT OWNER NAME LEGIBALLY:
I, as a witness, saw the owner of this property affix his signature to this owner affidavit, certifying that he is
not subject to licensure as a contractor or subcontractor in the state of Virginia.
WITNESS’ SIGNATURE: DATE: PLEASE PRINT WITNESS’ NAME LEGIBALLY:
OFFICE USE ONLY
FIRE PERMIT FEE:
$
OTHER FEE:
$
STATE LEVY:
$
TOTAL PERMIT FEE:
$
CASHIER: DATE: TENDER:
TZ EZ CF IDT
11/22/2017 9:07 AM
