Contractor Authorization Form - Virginia Building And Planning Department

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BUILDING AND PLANNING DEPARTMENT
1781 Greensville County Circle
Emporia, VA 23847
(434) 348-4232
(434) 348-0696 FAX
CONTRACTOR AUTHORIZATION FORM
_____________________________ is hereby authorized to obtain a ______________________
(Name)
(Building, Electrical, etc.)
permit on behalf of ____________________________________________ for the installation of
(Contractor Name)
_______________________________ at _______________________________.
(Permitted Work)
(Site Address)
By:______________________________________
Company Name: ___________________________
Address: _________________________________
_________________________________
Phone: _________________________________
License #: ________________________________
Expires: __________________________________
Date:_____________________________________

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