Fill and Sign the Virginia Agent Form

This document prepared by (and after recording return to): ) ) ) ) ) ) ) ) ) ) -------- Above This Line Reserved For Official Use Only-------------Name:       Firm/Company:       Address:       Address 2:       City, State, Zip:       Phone:       NOTICE TO MECHANIC LIEN AGENT AND OWNER/AGENT- INDIVIDUAL Code Sections 43-4.01 and 43-11 NOTICE TO MECHANIC LIEN AGENT FOR § 43-4.01 NOTICE Delivery by Certified Mail Date ________________ Name Mechanic Lien Agent: __________________________________ Address: _____________________________________________________________________ City: _____________________ : State: _____ Zip: ____________ Phone: _______________ Fax: _________________ Building Permit # ___________________ Date of Permit _________________ County/City _______________ Property Description on Building Permit: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Nature and Character of Claimant’s Contract (Type of Labor or Material to be Provided): ___________________________________________________________________________ NOTICE TO OWNER/AGENT FOR § 43-11 NOTICE Delivery by Certified Mail Date: ____________________ Name of Owner Agent: __________________________________ Address: __________________________________________________________________ City, State, Zip: _________________________________________________ Claimant Name: ____________________ Address: _________________________________________ _________________________________________________ _______________________________________________ City: __________________ State: _______ Zip: ____________ Phone: _________________ Fax: _________________ Notice to Mechanic Lien Agent and Owner/Agent Page 1 of 2 General Contractor Name: _________________________________ Address: __________________________ City: __________________ State: _____ Zip: _____________ Building Permit # __________________ Date of Permit _________________ County/City __________________ Copy of Building Permit attached: Yes No The Claimant is providing labor and/or material for the construction of improvements on the property described. The anticipated value of the labor and/or material to be provided and the probable amount of the claim will be ___________________________________ dollars ($ ______________ ). CLAIMANT SEEKS PAYMENT FOR LABOR PERFORMED OR MATERIAL FURNISHED. This Notice may create personal liability on the part of the Owner and General Contractor to pay this Claimant. This Notice should be sent before the Claimant begins work, if possible, under Virginia Code § 43-11 or within 30 days after Claimant begins work under Virginia Code § 43-4.01. __________________________________ Signature ______ _____________________________ Type or Print Name Given under my hand this the _____ day of ______________ 20 _______ . ________________________________ (Notary Public or Magistrate, et cetera.) Notice to Mechanic Lien Agent and Owner/Agent Page 2 of 2