Ross County Building Department

SUITE 201 15 NORTH PAINT STREET

CHILLICOTHE, OHIO 45601-3116
PHONE: 740-773-7200
FAX: 740-773-5124
E-MAIL: jillthomas@rosscountyohio.gov
www.rossplanningandbuilding.com

DAVID DUCKWORTH, CBO

APPLICATION FOR MANUFACTURED HOME INSTALLATION

(SUBMIT ONE APPLICATION FOR EACH STRUCTURE)
PLEASE PRINT OR TYPE
PERMIT #: _______________

1. Manufactured Home Owner's Name: _____________________________________________________________

Owners Current Address: ______________________________________City/St/Zip: __________________________
Phone#: ____________________________
2. Inspection reference used:
Manufacturers Installation Instructions Ohio Manufactured Home Installation Standard
Registered Architects OR Engineers Drawings Designers Name/Seal Number: _________________
3. A. General Information: New Install Relocate Size of MH: ____________________________
Used MH New MH Located in MH Park? Yes No
_____________________________________________________________
B.Is this in an incorporated Village? YES NO
_____________________________________________________________
C.Floodzone Y N

4. Dealer (or Individual): ______________________________________________________

Representatives Name: _____________________________________________________
Street Address: _________________________________ City/St/Zip: _________________________________
Telephone No.s: ______________________________ Email Address: ______________________________

5. Installer (s):
Name: ___________________________________ License#: ___________________
Responsibility: Footer Block Move Elec Set-up
Street Address: _______________________________ City/St/Zip: __________________________________
Phone#: _________________________________

Name: ___________________________________ License#: ___________________

Responsibility: Footer Block Move Elec Set-up
Street Address: _______________________________ City/St/Zip: __________________________________
Phone#: _________________________________

6. Manufacturer: __________________________ Date of Manufacture: __________________

Street Address: ______________________________ City/St/Zip: __________________________________
Serial#: _________________________________ HUD#: ____________________________
Thermal Zone: __________________________

7. Street Address of project: _____________________________________________________

City/St/Zip: ________________________________________________________________
Land Owners Name (if different than MH Owner): __________________________ County: _____________

8. FEES: Not in MH Park $575.00

In MH Park $475.00
A copy of your footer plan MUST be included with submission

CERTIFICATION: (OMHC 4781 Rules) Note: Fees do not include: re-inspection, or

I certify that I am the ______ Owner _______ Agent for the after-hours, weekends or holiday inspections.
owner and all information contained in this application is
true, accurate, and complete to the best of my knowledge. All MAKE CHECK PAYABLE TO:
official correspondence in connection with this application ROSS COUNTY BUILDING DEPARTMENT
should be sent to my attention.

Signature: ______________________________________________

Printed Name: __________________________________________

Title: _________________________ Date: __________________

Revised 4/28/2015JLT