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<br /> frAi:ZManufactured Home TripPermit Application
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<br /> r:"'c' y 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.
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<br /> Name: k-1'ovvt.eJ D Lyta- 0E Q?-- i t(•eySlni(,e
<br /> Address(including city,state,and ZIP):3g3g.�nidt /4 / Uy /hi ll+l�Shu,01 tL q 7 3 2-( _
<br /> Phone: sol- g /ZS(3 r _
<br /> Email: l U., 1l 1 II . .A ; i i i hl/uurl.-•� ._.
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<br /> Name: Pj&Age/ - TM/4Jh -i-Tira-1 .SpliY/— -
<br /> Address(including city,state,and ZIP):tE e j 9�,,, Anon Re/ -- a` /j� ale. Q7,-746
<br /> Phone: 541 --%'-.q---31.N4 r"
<br /> Email: ()\[ ID 1 i - Cbw�
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<br /> Home ID number(if known): I DMV X-plate number(if known):
<br /> Manufacturer:Po ____ I p p�' Model:3(r)&� 3(33)- Year: r -
<br /> HUD label numbers: (yit 6 55 t( 5 CGCG 551 (3(a
<br /> Serial numbers: l%`]\ ,pf- 4-Q t3 &1( 8 -A-6-,:se,. '•5'. Fr„°2J;•=1d✓:.`.rt. =I•i L::c-�C-c,:T,i's”-•�::i`-- .:•'w?!.Y.`i:; -".rte +,-.r^- .s-, vr: :tifE.%:"Y=w-41ab:�d^b .uy, „w,cw• .c'�-:�.1M'i\�••
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<br /> Current location(including city, state,ZIP): • 4 f'peongegiw. Onut Mill (fii 'I County: Li'yj lit
<br /> Manufactured home park name,if applicable:
<br /> ❑Oregon dealer lot I Dealer name:
<br /> ❑Out-of-state dealer lot L Dealer name and contact information:
<br /> Placement location(including city,state,ZIP): y4 3(Q') Ki ,Si(ale (.1ih!lyi ,M L '5114.1 _County: arty
<br /> Manufactured home park name,if applicable:
<br /> ❑Oregon dealer lot Dealer name: }}esyl tio \-),,,,,...,..4_0r 0', 'i - 'halo-go
<br /> Applicant signature: IA A / .e.o. ..i,�:, ,, /_,_/ . ,.ir , ...i1 ..
<br /> .. - . A. / /l• �..
<br /> Amount a
<br /> Trip permit(per section) -2.....< $5.00(70511-1195) $ (0 00 _
<br /> .�;:F+ �.k#�gS '''s;,i. ';� Z;�%l:r�lf.�;t;a`"''.. ?+r•'tr;w a r"••. •.-,....w��A,.��sf�_. $ I t • ]�
<br /> -;'{cam- iL.iiea5•i� 7�'Gcei;':.3>;~v;�fr.-< 4�e,;11rZ.x'�i. :..Cv�B aai s_atijiVa +OV
<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:( ) Departmeint use only
<br /> $
<br /> Cardholder signature Amount
<br /> Name of cardholder as shown on credit card
<br /> Credit card number Expiration
<br /> fi0.DC S
<br /> • Consumer and
<br /> Business Services
<br /> 440-5225.(10/17/C0M)
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