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`fir. P pex'rry 0iN(j <br /> Y ,°. fmanufactured Home Trip Permit Application rn 3343®' <br /> y,74 Department of Consumer and Business Services <br /> -' - <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:Beckyrae L Johnson <br /> Address(including city,state,and ZIP):8512 Holmquist Road SE,Aumsville, OR 97325 t <br /> Phone:503-830-1517 , <br /> Email: <br /> TRANSPORTER INFORMATION' _ :"*,.•t.::': ::. <br /> Name:Modern Building Systems <br /> Address(including city, state, and ZIP):9493 Porter Road, SE,Aumsville, OR 97325 <br /> Phone:503-749-4949 <br /> Email: <br /> , _ ' . �.HOME INFORMATION ,. - . j . '... . <br /> Home ID number(if known):147985 DMV X-plate number(if known): <br /> Manufacturer:Golden West Homes Model: Year:2004 <br /> HUD label numbers:ORE 0454937, ORE0454938 <br /> Serial numbers:GIOR23N28274A, GIOR23N28274B <br /> ` ADDRESS:INFORMATION :,. <br /> Current location(including city, state,ZIP):8514 Holmquist Road SE,Aumsville, OR 97325 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state, ZIP): 14th Street, Lyons, OR County:Linn <br /> Manufactured home park name,if applicable: 4g S az,"_/ <br /> ❑ Oregon dealer lot Dealer name: <br /> Applicant signature: ,f: <br /> `Amount:' <br /> Trip permit(per section) $5.00(70511-1195) $ <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 /> ❑Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount ' <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> ti'DCBS <br /> Consumer and <br /> Business Services <br /> 440-5225(I0/17/COM) <br />