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RUSSELL COUNTY BUILDING DEPARTMENT
137 Highland Dr. Suite D
Lebanon, VA 24266
Telephone: 276-889-8012
Fax: 276-889-8009
[email protected]
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:[email protected]
mailto:[email protected]
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
[email protected]
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:[email protected]
RUSSELL COUNTY BUILDING
DEPARTMENT
137 Highland Dr. Suite D
Lebanon, VA 2426
‘Telephone: 276-889-8012
Fax: 276-889-8009
[email protected]
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