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County of Cumberland Building Inspections Department P.O. Box 110 Cumberland, VA. 23040-0110 County Administrator (804) 492-3625 Building Inspections (804) 492-9114 Zoning Administrator (804) 492-3520 Fax # (804) 492-9224 Application Date: Permit Number: Please check the applicable permit type applying for: □ Electrical □ Signage (Plans are required to be submitted with application) Owner: Tenant: Name Daytime Telephone No. Mailing Address Contractor: (subs pg. 2) Name Daytime Telephone No. Mailing Address Property Information Location/Address: Tax Map/Parcel Number: Acres: Zoning District: Signs Ground Mount: x Roof Mount: x Electrical: Additional Information: Estimated Cost: Sign $ Electrical $ Name of Power Company you are with: Name account is in: Account number: Work/Project number given by Power Company to do work: ---PAGE BREAK--- General Contractor/ Subcontractor Information List all General Contractors/Subcontractors Below: Name/Type License State Contractor’s State Tradesman Cumberland County License Number Certification Number Business License Number Contractor Signature Date Sub-Contractor Signature Date Owner' Affidavit (must sign in front of notary) I, (signature here-→) of affirm that I am the owner of certain tract or parcel of land located at: and that I am applying for a building permit. I affirm that I am familiar with the prerequisites of 54.1-111 of the code of Virginia and I am not subject to licensure as a contractor or subcontractor. State of: County of: Signed and acknowledge on this day of , 20 , In the presence of the undersigned witness. Notary Expires / ID# Permit Fee Residential Commercial Electrical Electrical Structure Structure Subtotal Subtotal 2% State Levy 2% State Levy Total Total SIGN SIGN SIGN