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S, <br /> .c. Manufactured Home Trip. Permit Application• <br /> Department of Consumer and Business Services <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 /> oregon.gov <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 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 /> :APPL'ICANT''INFORMATION ,:': <br /> Name:HOMES DIRECT OF OREGON LLC-MILLERSBURG TANYA ABADILLA, OFFICE ADMINISTRATOR .. <br /> Address(including city,state,and ZIP):3838 PALM HARBOR DRIVE MILLERSBURG OR 97321 <br /> Phone:541-928-2083 <br /> Email:TANYA.ABADILLA@HOMES.DIRECT <br /> TRANSPORTER INFORMATION <br /> Name:BENNETT TRUCKING &TRANSPORT <br /> Address(including city,state, and ZIP):409 BIGHAM BROWN ROAD EAGLE PT OR 97524 <br /> Phone:541-879-3444- <br /> Email:yor@bennettig.com <br /> HOME INFORMATION <br /> Home ID number(if known):NEW DMV X-plate number(if known): _ <br /> Manufacturer:PALM HARBOR Model:3104G27523C Year: 2026 <br /> HUD label numbers: ORE 568963 ORE 568964 . <br /> Serial numbers: PHH310OR25-16412A, PHH3100R25-16412B <br /> ADDRESS INFORMATION • <br /> Current location(including city,state,ZIP):3838 PALM HARBOR DR NE MILLERSBURG,OR 97321 County:LINN <br /> Manufactured home park name,if applicable: <br /> El Oregon dealer lot Dealer name:HOMES DIRECT OF OREGON LLC <br /> El Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state, ZIP):4756 RIVERSIDE DR S, SALEM, OR 97306 County:MARION <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot :-aler name: ,G������ .... <br /> Applicant signaturo L/ <br /> Amount:` <br /> Trip permit(per section) $5.00(70511-1195) $ 10.00 <br /> 'TOTAL $ 10.00 <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 /> El Visa ❑MasterCard El Discover Phone:( ) <br /> Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> flv®CBS <br /> Consumer and <br /> Business Snakes <br /> 440-5225(10/17/COM) <br />