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2. MIDDLESEX COUNTY ADDENDUM TO BUILDING PERMIT - ELECTRICAL
3. Permit #
5. First Name
6. Last Name
8. Mailing Address
10. City
11. State
12. Zip Code
16. Site Address
18. City
19. State
20. Zip Code
24. Air Handler @$2.00 each
25. #
26. Total Cost - Air Handlers
28. Range @ $2.00 each
29. #
30. Total Cost - Ranges
32. Water Heater @ $2.00 each
33. #
34. Total Cost - Water Heaters
36. Motors @ $2.00 each
37. #
38. Total Cost - Motors
40. Other Circuits @ $2.00 each
41. #
42. Total Cost - Other Circuits
44. Panel Size @ $.25/ amp
45. #
46. Total Cost - Panel Size
50. DOM WORK ORDER#
52. Sub Panel @ $.25 / amp
53. #
54. Total Cost - Sub Panel
56. Electric Heat @ $1.00 / K/W
57. #
58. Total Cost - Electric Heat
60. Backup Generator @ $50
61. #
62. Total Cost - Backup Generator
64. Residential Photo-voltaic System @ $50
65. #
66. Total Cost - Residential Photo-voltaic Systems
68. Commercial Photo-voltaic system @ $1.50 /DC/ kW generated
69. #
70. Total Cost - Commercial Photo-voltaic systems
72. Reconnect Service @ $50
73. #
74. Total Cost - Reconnect Services
76. Relocate Service @ $50
77. #
78. Total Cost - Relocate Services
80. Temporary Service @ $50
81. #
82. Total Cost - Temporary Services
84. PERMIT FEE (or $50 minimum):
85. Total Cost - Permit Fee
87. STATE MANDATED 2% FEE LEVY: (PERMIT FEE X .02)
88. -----------------
89. STATE MANDATED 2% FEE LEVY: (PERMIT FEE X .02) Total
91. Total Amount Due
95. Contractor:
96. Email Address
98. Address
100. City
101. State
102. Zip Code
104. Phone Number
105. Fax Number
107. LICENSE NUMBER:
108. EXPIRATION DATE:

110. ATTACH COPY OF STATE CONTRACTOR'S LICENSE 

     I hereby certify that I have the authority to make the foregoing application, that the application is correct, and that the electrical installation will conform to the National Electric Code as currently adopted. 

114. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
116. Electronic Signature
117. Date
     Date

     Date
118. Date Permit Issued
     Date Permit Issued

     Date Permit Issued

123. MIDDLESEX COUNTY BUILDING DEPARTMENT, P.O. BOX 428, SALUDA, VA, 23149 PHONE: (804) 758-4305     

     www.co.middlesex.va.us/planning&communitydevelopment/applications

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125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit

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