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r: i, -, • . , <br /> ,e_ ' ?>,. Manufactured Home Trip Permit Application <br /> ^FMS__i* , <br /> I•^ Department of Consumer and Business Services <br /> fi•1�::i��r�:r; •r( <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 /> :.k.':'::''':, ,,.... .-. ' .....f, `. .._; APPLICANT:INFORMATION '''.'::',::. .''',''T = _ <br /> Name: Patricia L McCormick, D Scott McCormick <br /> Address(including city,state,and ZIP): PO Box 1245 Turner,Oregon 97392 <br /> Phone: 503-559-4220 503-559-6464 <br /> Email: tmccor6110@aol.com <br /> . TRANSPORTERINFORMATION :-i-''''.,:),:7:::..,::''': <br /> Name:Phil Sterling Home Service Inc <br /> Address(including city,state,and ZIP):17230 Beck Road, Dallas, Oregon 97338 <br />- Phone: 503-932-2629 <br /> Email: <br /> .; HOME INFORMATION <br /> Home ID number(if known): 399242 DMV X-plate number(if known):X61736002 <br /> Manufacturer: Skyline Model: Oaksprings Year:1985 <br /> HUD label numbers: <br /> Serial numbers: 32910120U <br /> t,. .. ADDRESS INFORMATION_.;' . . .. , <br /> Current location(including city,state,ZIP): 12234 Summit Loop SE,Turner, Oregon 97392 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):12793 Brick Rd SE,Turner Oregon 97392 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot. Dealer name: <br /> Applicant signature: zo `iin�..47,: , 9�a r. fri--e-,1 <br /> - Amounts <br /> Trip permit(per section) $5.00(70511-1195) $10.00 <br /> '_ - _ - :1 ,. - .,,. TOTAL _ $10.00 <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 0 MasterCard 0 Discover Phone:603) 559-6464 Department use only <br /> _70rO�Pr-e/yP-ems $10.00 <br /> Cardholder signature Amount <br /> D McCormick <br /> Name of cardholder as shown on credit card411111111111.111 <br /> 03 122 <br /> Credit card number Expiration <br /> 5BS <br /> -1 Consumerend <br /> BusinessService <br /> 440-5225(10/17/COM) <br />