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r_ <br /> II ) <br /> It57a -13I.u,e �I �eYo►� G-It) <br /> rq fro re-( ( � 3,24 3 <br /> -. 'ia 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 /> 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 /> 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(if known): <br /> Manufacturer:CAVCO/PALM HARBOR Model:3104G24402A Year: 2026 <br /> HUD label numbers: ORE 571140 ORE 571141 <br /> Serial numbers: CAV3100R26-16840A, CAV310OR26-16840E <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 /> 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): 11572 BLUE HERON LN NE,AURORA, OR 97002 County:MARION <br /> Manufactured home park name, if applic ble: <br /> ❑Oregon dealer lot er name: �������� <br /> Applicant signatur . <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 /> ❑Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> Cardholder signature Amount • <br /> Name of cardholder as shown on credit card <br /> • <br /> • <br /> Credit card number Expiration <br /> • <br /> vNDC65 • <br /> • <br /> Consumer and <br /> Business Services - <br /> 440-5225(10/17/COM) <br />