Laserfiche WebLink
5 316_S <br /> . • <br /> • 4 � Manufactured Home Trip Permit Application <br /> g% <br /> Department or Consumer and Business Services <br /> BuildingCodes Division • <br /> Ncr <br /> •Phone:50 - ax_503-378-4101 <br /> 1535 Edgewater St.NW,Salem,Oregon• 3 378530•F <br /> • Web: oregon.gov/bcd•Email:mhods.bcd ore on gav <br /> • <br /> This application must be submitted with a valid tax certification from the county in which the home is currently located, <br /> as well as the countythe home is movingto.A valid tax certification is one that has been certified bythe countyand <br /> submitted before the expiration date provided by the county at the time of certif cation. <br /> 4tr } i �. .#110,40): n x�•q f�{� ��-.r y•.� L`Se��i°�,fi'4 L• <br /> Name: .3",,,.ye,s l�erS <br /> Address(includingcity,state,and ZIP : 6 9 ' <br /> 6z ek 4 5 <br /> ty, ) o t� <br /> 6 >t- a � <br /> �A� a, 'rkr.�i5t? <br /> 5t� y � <br /> • _ Phone: (ATO—55391-.-6 Z$O <br /> . Email: a'a.s+�C 0,4 qQ 0.kr,oo.. C.pyv`n r <br /> rgn <br /> Name: �i.c e.-f o r }Aowve.�,!'a n.1ort <br /> Address(including city,state,and ZIP): 7 ��)- 64-t• 'S-t; �' - t ,,� d(� 973 5 a <br /> Phone: 5b3-5-5-(_ 34-619- _ <br /> Email: r - l� .l1-c.o <br /> Home ID number(if known): 392512 f DMV X-plate number(if known): <br /> Manufacturer:Golden West/Karsten Albany##972 I Model:72DRM28483CH16 Year: 2016 <br /> HUD label numbers: ORE 531206,ORE 531207 <br /> • Serial numbers:Al.60361790RA,ALB036179ORB • <br /> � uy�ugd+ tr. s� tfi!'}]���� .^e1- �i� !.��ty�y�y ��u■1t��1`� p} q y � e �k �,� �.-. k,,yy9�f���; <br /> My r AYN'i� x*cSMCAR4 •41Vi�[',!�� 'rden:'1,4i�!CN`1Y."c v�t�7 G'•��.-k�ZOVI � s:7T;RI•h . is rS."l5 <br /> Current location(including city,state,ZIP): 3859 MJB Place,Salem,OR 97317 County: Marion <br /> Manufactured home park name,if applicable: ' <br /> D Oregon dealer lot I Dealer name: - - <br /> D Out-of-state dealer lot I Dealer name and contact information: <br /> Placement location(including city,state,ZIP): X37 5>Ear k Q,t- Magq iaq_ (Pr I County. i-te_ <br /> Manufactured home park name,if applicable: <br /> D Oregon dealer lot I Dealer name: . <br /> Applicant signature: - <br /> . Trip .ermit per section 55.00 05511-1119h S <br /> $ I <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 /> D Visa D MasterCard 0 Discover Phone:( ) • Department use only <br /> $ - • . <br /> Cardholder signature . Amount <br /> • <br /> Name of cardholder as shown on credit caul <br /> • <br /> Credit and number Expiration <br /> 1 <br /> 4t;, Di.'BS- <br /> 440-5225(10/17/COM) . <br />