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I I(Yl ase le S-i- 3ee -4ev 611 <br /> 1YU4M1UW4-1.611 VVI 111D1111+ it 1119 1 1+111111. L3i1J10a11C11.a1D11 <br /> Department of Consumer and Business Services .B(. L <br /> s9/ 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: Re Nj -11,415 <br /> Address (including city,state,and ZIP): blot 'Sar.jN6 C-���A®G-(L R,p, LJ 1t.5 s a sh/i t_eC-, O( S-a- d <br /> Phone: Sol -3[a o' t <br /> I <br /> Email: A C,S e(Lv s s t a.pAL0.-C Mm k—c.4 <br /> TRANSPORTER:INFORMATION <br /> Name: A `1. o--r-c Ro \-VI IA.� <br /> Address(including city,state,and ZIP): 17,6 ( o X (0 V G - E-g. to R. cti e-t wi <br /> Phone: S41-Q! c-ICA CD. <br /> Email: ikl-o►cale,R c \Mko®.Co <br /> HOME INFORMATION =. <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer: piskl.,d i.ANK6 criL N6 V-.3 Model:NI Lkts(453 ® Year:D.()`5' <br /> HUD label numbers: op,E c 513 <br /> '3 <br /> Serial numbers: p8A3 c (3 d 44 Cid PNA-13\dO'R\;‘l'L4Lt(cL. <br /> ADDRE:SS_INPO RMATION <br /> Current location(including city,state,ZIP): (Acts oL0eY ST, sC I5m6 `OR County:par,16,0 <br /> Manufactured home park name,if applicable: 14 - <br /> ❑Oregon dealer lot Dealer name: 1.414 <br /> ❑Out-of-state dealer lot Dealer name and contact information: t J 14 <br /> Placement location(including city,state,ZIP): k 5)_.). t A p'izs-Y , f 0 County: 43 <br /> plicable: t ' 6 <br /> Manufactured home p ark name,i ... � <br /> O Oregon dealer lot De ler rig W10.,, <br /> Applicant signature: <br /> A_m ou,nt <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 0 Discover Phone:( ) <br /> Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> :DCBS <br /> Consumerand <br />