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5355 <br /> R \ley- Road K) 5' L , Ye__ 2.e___r-- <br /> . <br /> Manufactured Home Trip Permit Application m 3 5 8c 8 <br /> k4, <br /> :"", -� Department of Consumer and Business Services <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: Martin Howell <br /> Address(including city, state,and ZIP): 5355 River Rd. N #61 Keizer, OR 97303 <br /> Phone: 503-304-0003 <br /> Email: mcnarycr,ipgmhc.con <br /> TRANSPORTER INFORMATION <br /> Name: Rc nnett Truck Trac ort <br /> Address(including city, state, and ZIP): 1360 Industiral Ave. Woodburn, OR 97071 <br /> Phone: 503-981-7939 <br /> Email: wbo@bennettig.com <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer: Fleetwood Model:Waverly Crest/210WC28563L Year: 2019 <br /> HUD label numbers: <br /> Serial numbers: FLE210OR19-20342AB <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP): 2655 Progress Way Wooburn, OR 97071 County: Marion <br /> Manufactured home park name, if applicable: Fleetwood Homes <br /> ❑Oregon dealer lot Dealer name: Fleetwood Factory <br /> ❑Out-of-state dealer lot Dealer name and contact information: Fleetwood Homes <br /> Placement location(including city,state,ZIP): 5355 River Rd. N #51 Keizer, OR 97303 County: Marion <br /> Manufactured home park name, if applicable: - McNary Oaks MHC <br /> ❑ Oregon dealer lot Dealer name: <br /> Applicant signature: <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 /> • I, BS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />