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f <br /> Manufactured Home Trip Permit Application I aiD6( <br /> ` 7* = Department of Consumer and Business Services <br /> 5 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.INFORMATIOPI; <br /> Name:ORCHARD MHP <br /> Address (including city, state, and ZIP): 1351 31ST AVE NE SALEM, OR 97301 <br /> Phone:503.362.1281 <br /> Email:ORCHARDMOBILEHOMEPARK@GMAIL.COM <br /> TRANSPORTER INFORMATION <br /> Name:SITE INSPECTION SERVICES <br /> Address (including city, state, and ZIP):2390 ALAMEDA ST. NE SALEM, OR 97301 <br /> Phone:503.375.9440 <br /> Email: <br /> HO'.ME INFORMATION ". . <br /> Home ID number(if]mown):230652 DMV X-plate number W.known): <br /> Manufacturer:FLEETWOOD Model:NA Year:1978 <br /> I-IUD label numbers: <br /> Serial numbers:ORFL 1 A850381557 <br /> ADDRESS INFORMATION, F w <br /> Current location (including'city, state, ZIP):4155 LANCASTER DR NE#62 SALEM, OR 97305 County:MARION <br /> Manufactured home park name, if applicable:CHEMEKETA MV <br /> ❑ Oregon dealer lot Dealer name: <br /> ❑ Out-of-state dealer lot Dealer name and contact information: <br /> Placement location (including city, state, ZIP):3125 ELLIS AVE NE#67 SALEM, OR 97301 County:MARION <br /> Manufactured home park name, if applicable:ORCHARD MHP <br /> ❑ Oregon dealer lot D aler name: <br /> Applicant signature: /B`2G(5 <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> , TOTAL $5.00 <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 ❑Di4cover Phone:( ) <br /> Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> t,DCBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />