---
type: document
title: RC Manufactured Home Permit 202303031102446773
file: ../RC Manufactured Home Permit_202303031102446773.pdf
tags:
  - Russell_County
  - Building_Department
docDate: null
contentType: application/pdf
contentLength: 193624
sha256sum: 4454c9e7d503e532da97c33403c31823d837f7ddc1ef8ed1b89183dd02f00cb7
sha1sum: 869882f9e7ca3d8e23c1ebad7b5bcd4fb5eb8607
---

RUSSELL COUNTY BUILDING DEPARTMENT 
137 Highland Dr. Suite D 
Lebanon, VA 24266 
Telephone: 276-889-8012 
Fax: 276-889-8009 
build@russellcountyva.us 
Josh Stinson—Building Official 

Date: 

Russell County Manufactured/Mobile Home Permit Application 

Type of Work 
Singlewide Doublewide Camper

Construction 
Category New Used Relocation 

Applicant 
(Permit Holder)              Who will be considered the permit holder?      Property Owner         Contractor 

Property Owner 

Name: Email Address: 

Mailing Address: Phone: 

Property 
Information 

Tax Map I.D# Septic# Water Source 

Flood Zone: 

Applicant 
Information: 

Name: 

Address: 

City, State, Zip 

Home Information 

Manufacturer Year Size 

#Bedrooms #Full Baths #Half Baths #Stories 

Estimated Cost 

Type of Heat Electric Heat Pump Gas Wood Stove Solar 

Foundation Slab Crawl Basement 

Project 
Description 

mailto:build@russellcountyva.us
mailto:build@russellcountyva.us
RUSSELL COUNTY BUILDING DEPARTMENT Date:
197 Highland Dr. Suite D

Lebanon, VA 24266

‘Telephone: 276-889-8012

Fax: 276-889-8009

buildarusselicountyva.us

Josh Stinson—Building Official

Russell County Manufactured/Mobile Home Permit Application

Type of Work
single Doubiewide cme
Construction —
Category Now Used Relocation|_]
“Applicant im
(Permit Holder) Who willbe considered the permit holder? Property Owner Contractor
Name Email Adres
Property Owner ring Address Phone:

Tax Map LD# Septic# ‘Water Source
Property Flood Zone:
Information
‘Applicant | Name:

Information: — [age

City, State, Zip
‘Manufacturer ‘Year ‘Size
Home Information =
Bedrooms Full Baths all Baths *iories
Estimated Cost

"Type of Heat Electric Heat Pump Wood Stove

Foundation Slab Crawl Basement
Project

Description





RUSSELL COUNTY BUILDING 
DEPARTMENT 
137 Highland Dr. Suite D 
Lebanon, VA 2426 
Telephone: 276-889-8012 
Fax: 276-889-8009 
build@russellcountyva.us 
Josh Stinson—Building Official 

 
 
 
 

 

 
 

Contractor/ 
Sub -Contractor  

Information 

Business Name: 

Contact Name: 

Address: City/State: Zip Code: 

State License#: Exp. Date: Phone: 

 

 

 

Mechanics Lien 
Agent 

Name: 

Address: 

City State Zip Code 

 

I hereby certify that I am the owner of the record of the herein described property, or that the proposed work has been authorized by the owner 
of record and that I have been authorized to make this application as a designated agent I agree to conform to all applicable state and local 
regulations, rules and policies and such shall be deemed a condition entering into the exercise of the permit. In addition, if a permit is issued, I 
certify that the code official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hour 
for the purpose of enforcing the provisions of the applicable code(s). I affirm that all information on this application is true and accurate. 

Signature: Date: 

 

FOR OFFICE USE ONLY Date Received: 

Building Permit Fee: Levy: Total Fee Amount 

 
 

mailto:build@russellcountyva.us
RUSSELL COUNTY BUILDING
DEPARTMENT

137 Highland Dr. Suite D
Lebanon, VA 2426

‘Telephone: 276-889-8012

Fax: 276-889-8009

build@russellcountyva.us
Josh Stinson—Building Official

‘Business Name:

Contractor!
Sub -Contractor
Information

‘Contact Name:

‘Address City/State: Zip Code:

State License Exp. Date Phone:

Name:

Ares

Gy Siate Zip Code

Thereby certify that lam the owner ofthe record of the herein deseribed property, or that the proposed work has been authorized by the owner
of record and that I have been authorized to make this application as a designated agent I agree to conform to all applicable state and local
regulations, rules and policies and such shall be deemed a condition entering into the exercise of the permit. In addition, if a permit is issued, 1
certify that the code official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hour
for the purpose of enforcing the provisions of the applicable code(s). L affirm that all information on this application is true and accurate.

Signature Date:

FOR OFFICE USE ONLY Date Reecived:

Bullding Permit Fee: ‘Total Fee Amount




	RUSSELL COUNTY BUILDING DEPARTMENT
	RUSSELL COUNTY BUILDING DEPARTMENT

	Type of Work: 
	Singlewide: Off
	Doublewide: Off
	Camper: Off
	Construction Category: 
	New: 
	Used: Off
	Relocation: Off
	Applicant Permit Holder Who will be considered the permit holder Property Owner Contractor: 
	Name: 
	Email Address: 
	Mailing Address: 
	Phone: 
	undefined: 
	Tax Map ID: 
	Septic: 
	Water Source: 
	Flood Zone: 
	Applicant: 
	Name_2: 
	City State Zip: 
	Applicant InformationRow1: 
	City State ZipRow1: 
	Home Information: 
	Manufacturer: 
	Year: 
	Size: 
	Bedrooms: 
	Full Baths: 
	Half Baths: 
	Stories: 
	Estimated Cost: 
	undefined_2: 
	Type of Heat: 
	Electric: 
	Heat Pump: 
	Gas: 
	Wood Stove: 
	Solar: 
	undefined_3: 
	Foundation: 
	Slab: 
	Crawl: 
	Basement: 
	Project: 
	Project Description: 
	undefined_4: 
	Contractor Sub Contractor Information: 
	Business Name: 
	Contact Name: 
	Address: 
	CityState: 
	Zip Code: 
	State License: 
	Exp Date: 
	Phone_2: 
	Mechanics Lien Agent: 
	Name_3: 
	Address_2: 
	City: 
	State: 
	Zip Code_2: 
	Signature: 
	Date: 
	FOR OFFICE USE ONLY Date Received: 
	Building Permit Fee Levy Total Fee Amount: 
	Check Box16: Off
	Check Box17: Off