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it \ `'a a Son ` 0 Gcci-e$ <br /> Manufactured Home Trip Permit Application <br /> ,�.,,',""'` r Department of Consumer and Business Services <br /> y Building Codes Division <br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530•Fax: 503-378-4101 <br /> Web: oregon.gdv/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 /> APPLICANT'INFORMATION ., <br /> .Name: ( /IBC - Dacii Mkt O1A <br /> Address(including city,state,and ZIP): mg? li x i t,{ipi(Q cArtAivliAfAta SA- c Sc ,02_ J1130 2- <br /> Phone: 6g-q4 -32'1 <br /> Email: C,{Ne I,CrA iD CAf!'1CGwl- rip - , <br /> TRANSPORTER:INFORMATION <br /> Name: 'jl yu, j-i ) <br /> Address(including city,state,and ZIP): --W I eimitten OR 50 a 1 0i_ 41?`114 <br /> Phone: Clcf- 4,4 ' 556 l <br /> Email: h (AL IIIIIAJ @ l4ak1 . CAM <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer: Model: Year: <br /> HUD label numbers: <br /> Serial numbers: <br /> ADDRESS INFORMATION i <br /> Current location(including city,state,ZIP): j(i65 WI If.) we- WC(,q Wed hurl() County: MaiVipjl <br /> Manufactured home park name,if applicable: JL` <br /> Ij Oregon dealer lot Dealer name: COAL 6- M v 1L <br /> `iYl <br /> /❑'Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP): 22 Z Ki sikn, 4) j b(i1 2S County: (1141yjii i <br /> r <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot laler name: <br /> Applicant signature: MI,LI , A <br /> 4,- <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $ 5 <br /> - TOTAL $ ,.-- <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 MasterCard ❑Discover Phone: ?j 0 q -3 <br /> C�+�) �' � )z1 'I Department use only <br /> b li dt,'_ &I-4 .__ $ C-a ..-- <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> 9'5r1) le It to 4 ti'5 1051 )D l2-r'1 <br /> Credit card number Expiration <br /> tIiJCBS <br /> ' Consumer and <br /> K Business Servir i <br /> 440-5225(10/17/COM) <br />