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Manufactured Home Trip Permit Application. <br /> Department of Consumer and Business Services • . <br /> es Building Codes Division • <br /> I535-Edgewater St. NW, Salem, Oregon• Phone: 503-378-4530 • Fax: 503-378-410I <br /> Web:.oregon.gov/bed • Email: mhods.bcd(2loregon.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,thehome is moving to. A Valid lax 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 /> APPLICANT 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(ifknrnrn): . <br /> Manufacturer:CAVCO/PALM HARBOR Model:310HD30763H Year: 2026 • <br /> -IUD label numbers: .ORE 570148 ORE 570149 <br /> Serial.numbers;.CAV3100R25-16594A, CAV3100R25-16594B <br /> • <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 /> E Oregon dealer lot.' Dealer name:HOMES DIRECT OF OREGON LLC. <br /> ❑Out-of-state dealer lot Dealer name and contact information: • <br /> Placement location(including city,state,ZIP): 8776SKYLINE RD S, SALEM, OR 97306 County:MARION <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot •tler name: <br /> Applicant signatc • <br /> • �_....T <br /> • <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $ 10.00 <br /> TOTAL $ 10.00 <br /> • <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 /> Visa ❑MasterCard ❑ Discover Phone:( ) • <br /> Department use only <br /> •$ . <br /> Cardholder signature Amount • <br /> • <br /> Name of cardholder as shown on credit card <br /> Credit card:numher IiNhiration . <br /> V1gt®CB5 • <br /> Consumer and <br /> Business Services <br /> 440-5225(I(1/17/COM) . <br />