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Manufactured Home Trip Permit Application y g 3S I <br /> %MAW Department of Consumer and Business Services • <br /> `�gq i <br /> Building Codes Division <br /> 1535 Edgewater St.NW, Salem, Oregon•Phone: 503-3784530 •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: R,6 � Tu.) <br /> Address(including city, state, and ZIP): SNA N ik .. . .(yva 0O cr)®`)d . <br /> Phone: 5'63--`11c,-3t ° • <br /> Email: ACSelzikeSS,, t GIAts\l,• . <br /> TRANSPORTER INFORMATION <br /> Name: A4011-- w 51,LE tAdwke <br /> Address(including city, state, and ZIP):?,,a. (t . t Vee l Q on <br /> Phone:541, �3 '_xcactu, <br /> Email: <br /> • HOME.INFORMATION . . <br /> Home ID number(if known): 3 1 DMV X-plate number(if known): <br /> Manufacturer: pA,L4A, L452. 4,5s Model: Nfi4-s. 6S30 Year: X15 <br /> HUD label numbers: ORE • 60,5 SX1 13 <br /> Serial numbers: pE\%V'l i Od Risl]Ll-410(SiPP SIV4L1(a i <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP): fa ®o3 l( sE ��� s;p 4.^,1 oft_ 411 311 County:m(2,18o <br /> Manufactured home park name,if applicable: 1Ni$ <br /> ❑Oregon dealer lot Dealer name: w k <br /> D Out-of-state dealer lot Dealer name and contact information: IA(L <br /> Placement location(including city,state,ZIP): S awe's:sT S6 zt,t5,, O& County:14 CU <br /> Manufactured home park name,i. .plicable: 141A <br /> ❑Oregon dealer lot De ler ame: . _14 <br /> Applicant signature • <br /> : <►_ <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 /> • <br /> Name of cardholder as shown on credit card <br /> • <br /> Credit card number Expiration <br /> • <br /> (Pq•DCBS <br /> - Consumer and <br /> BusinessServkes <br /> 440-5225(10/17/C0M) <br />