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MbVI W 40 6 vf-mar Coun1y I.V, a47a(03-
<br /> R ' ,Manufactured Home Trip Permit Application i 3 O 7 Co
<br /> 1'4'1 1 Deartment.of Consumer and Business Services
<br /> J
<br /> Building Codes Division
<br /> 1535 Edgewater St.NW, Salem, Oregon•Phone: 503-378-4530 •Fax: 503-378-4101
<br /> Web: oregon.gov/bcd•Email: mhods.bcd@oregon.gov
<br /> This application must be submitted with a valid tax certification fromthe county in which the home is currently located,
<br /> as well as the county the home is moving to.A valid tax certification is one that has been certified by the county and
<br /> submitted before the expiration date provided by the county at the time of certification.
<br /> : :-:1;:'..':',, ,':' ? , -::;APPLICANT",INFORMATION ti
<br /> Name: 34(C t F rde,rer
<br /> • Address(including city,state, and ZIP):( 0g W s l'iAzd 960.j- tijcv,1 j Cson Az. R.6-71/3
<br /> Phone: 54 t - 94.5 - 2(0`l5
<br /> Email: um LJ CIA/ex inq 2010 t5 t jah co .corn
<br /> TRANSPORTERINFORMATION . .
<br /> CT \A);
<br /> lson—T'rens por-�- . .
<br /> Name:Address(including city,state,and ZIP): r,o & to 52. Lc,to w Q 9t 8 fo 3 S
<br /> Phone: 544 1 -ct --c-i ( I . .
<br /> Email:-T\wr(sr,vt 24 mala osij[4Jrvpo ,colon
<br /> ,.HOME INFORMATION;-,
<br /> Home ID number(if known): 2�(7D Co 3 DMV X-plate number(if known):
<br /> Manufacturer: nee{ uDee8. Model: Ref Si,. r C.. Year: (9$'.5
<br /> HUD label numbers:ORE- 13 z, 7 6 2. / Ogg I 2 7/03
<br /> Serial numbers OR V t.. 2 A F21 y gc�(a 10 9A /,bRFL_2 f ,P2.1�30 1((010 9 B
<br /> '"~ - - ,ADDRESS INFORMATION--;:'-
<br /> Current location(including city; state,LIP): 1 3ozg Bc4h I e.hG ?E C crvC'.ts IO d. : County:Aar ov,
<br /> Manufactured home park name,if applicable: e170 24.
<br /> ❑ Oregon dealer lot , Dealer name: '
<br /> ❑Out-of-state dealer lot . Dealer name and contact information:
<br /> Placement location(including city, state;ZIP): 40-7 2.1 pt.vis Ln Gmss v4lletj p'R, County: S v.m63,1Manufactured home park name,if applicable: 9102.1
<br /> ❑ Oregon dealer lot Dealer name:
<br /> Applicant signa i.h,t_
<br /> Amount
<br /> Trip permit(per section) " $5.00(70511-1195) $ /Q.
<br /> :, . , ;:.:.,..,.:;',• ,-,-:,;:', ',:':',,l',::',--'•';: .. _., TO,TAL; $ 10,09---
<br /> .
<br /> Make
<br /> O---
<br /> Make check or money order payable to Department of Consumer and Business Services.If paying by credit card,applicant
<br /> must sign credit card information box.Do not send cash.Secure fax:503-947-2333
<br /> 0 Visa 0 MasterCard 0 Discover ' Phone:( ) -
<br /> Department use only
<br />( Cardholder signature Amount RECEIVED,
<br /> Name of cardholder as shown on credit card J U N 2 9 2021
<br /> ( / 11/1RIOPV COUNTY
<br /> Credit card number Expiration ASSESSOR
<br /> \tiq
<br /> ' CBS
<br /> ":-j / (onsumerand
<br /> BusfnessServkes _ -
<br /> 440-5225(10/17/COM)
<br />
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