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r <br /> '1; 3 qq5 <br /> acme Manufactured Home Trip Permit Application <br /> BCC�eodos Form <br /> D�sn Department of Consumer and Business Services•Building Codes Division <br /> Depart VEIConsumer Mailing address: P.O. Box 14470, Salem, OR 97309-0404 <br /> and Business Services <br /> 1535 Edgewater St.NW, Salem, OR 97304 5225 <br /> Phone: 503-378-4530 • Email:mhods.bcd@dcbs.oregon.gov <br /> Web: mhods.oregon.gov <br /> 17 :: .: ...-£ } .0.0 i4NT I kOMATION,#(Please dintM 3 . , .r !MP <br /> ❑Dealer/seller ❑Lender ❑Escrow/title agent ❑Owner/buyer ❑Legal representative <br /> Name: T & L TRUCKING, INC <br /> (Last,First,Middle) Phone: 971-209-5757 <br /> Address: 9874 GOLF CLUB RD SE UNIT 13 <br /> (street or P.O.box) <br /> City: STAYTON State: OR ZIP: 97383 <br /> Email: tandltruckinginc@gmail.com <br /> $ gf a _: N '. TRANSPORTER;INFORMATIbN�r <br /> _,.._ ;.E_�.�_ .._..... c.zf-...: .. ,..r.,:. _ -c��.c�k-�x?��a <br /> Name' T & L TRUCKING, INC(Last,First,Middle) Phone: 971-209-5757 <br /> Address: 9874 GOLF CLUB RD SE UNIT 13 <br /> (street or P.O.box) <br /> City: STAYTON <br /> State: OR ZIP: 97383 <br /> Email: tandltruckinginc@gmail.com <br /> x ,: . >a '.:w <br /> 4',, v, � max. .r �, HOME INFORMATION <br /> Home ID(if known): <br /> Manufacturer: PALM HARBOR HOMES Year: 2026 <br /> Current Address: 3737 NE PALM HARBOR DR <br /> City: MILLERSBURG County: LINN State: OR <br /> ZIP: 97321 <br /> Serial number(s): 16954-A&B HUD label number(s): <br /> (required if new home) <br /> 3, .u -_` ADDRESSINFflRMATION `.a W Ux; n; <br /> Current Address:. <br /> City: County: State: ZIP <br /> Manufactured home park name: (If applicable) <br /> ❑Oregon dealer lot 0 Out-of-state dealer lot Dealer name: <br /> Dealer contact information: <br /> Placement location: 14077 DUCKFLAT RD <br /> City: TURNER County: MARION State: OR ZIP 97392 <br /> Manufactured home park name: (If applicable) <br /> ❑Oregon dealer lot 0 Out-of-state dea Dealer name: <br /> Dea er c to• infonn, 'on: <br /> Applicant signature: <br /> Trip permit(per section) $5.00(70511/1195) $ <br /> TOTAL $ <br /> Make check or money order payable to Department of Consumer&Business Services.If paying by credit card,applicant <br /> must sign the credit card information box.Do not send cash.Do not email.Secure fax for credit card payments:503-947-2333 <br /> ❑Visa ❑MasterCard ❑Discover Phone: DCBS Fiscal use only: 70511/1195 <br /> 3 <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration date <br /> 440-5225(12/25/COM) Manufactured home trip permit application <br />