Permit Application Center
Land Development Services
12055 Government Center Parkway, Suite 230, Fairfax, VA 22035
Phone: 703-222-0801, TTY 711
This permit authorization form certifies that the party listed (authorized agent), who is not a
lessee, licensed architect, engineer, or contractor, has been granted authorization to obtain a
permit(s) on behalf of a property owner. This form must be filled out completely by the property
owner if another party is submitting an application(s) on the owner’s behalf. This form must be
submitted prior to issuance of any permit.
I, , the owner of the property listed below,
certify that I have granted,
as my duly authorized agent and give permission to obtain the permits necessary for the
construction or installation of:
at the following address:
I understand that the permits obtained pursuant to this permit authorization form will be in my
name and that I am acting as contractor for this project. Subject to the note below, I accept full
responsibility for the work performed.
Property Owner’s Name:
Property Owner’s Email: Phone:
Signature of Property Owner: Date:
Note to the Property Owners
The Virginia Uniform Statewide Building Code requires inspection of the work identified on the permit. Any
work done contrary to an applicable code or ordinance may result in a corrective work order, stop work order,
or notice of violation. If you made arrangements with a contractor to perform work on your property, Fairfax
County strongly suggests that the contractor secure the necessary permit in their name. When a contractor
obtains a permit in their name, they indicate their responsibility for the work performed. When a contractor
applies for a permit, County staff will verify that the contractor is licensed as required by state and local laws.
When you (property owner) sign this permit authorization form you are obtaining a permit(s) in your name for
work that may be performed by a contractor. Any resulting code violations or enforcement action may
necessarily include you as the permit holder. If you have any questions regarding this matter, please call the
Customer and Technical Support Center, at 703-222-0801 prior to signing this form. Updated 09/2018