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manufactured Home Trip Permit Application '•`m '"" tll• Department of Consumer and Business Services Building Codes Division 1535 Edgewater St. NW, Salem, Oregon • Phone: 503-378-4530 • Fax: 503-378-4101 Web: oregon.gov/bcd • Email: nlhods.bcd@oregon.gov This application must be submitted with a valid tax certification from the county in which the home is currently located, as well as the county the home is moving to, A valid tax certification is one that has been certified by the county and submitted before the expiration date provided by the county at the time of certification. APPLICANT INFORMATION Name:ORCHARD MHP • Address (including city, state, and ZIP): 1351 31ST AVE NE SALEM, OR 97301 Phone:503.362.1281 Email:ORCHARDMOBILEHOMEPARK@GMAIL.COM - TRANSPORTER INFORMATION . Name:SITE INSPECTION SERVICES Address (including city, state, and ZIP):2390 ALAMEDA ST. NE SALEM, OR 97301 Phone:503.375.9440 Email: HOME INFORMATION Home ID number((f known):230652 DMV X-plate number(if known): Manufacturer:FLEETWOOD Model:NA Year: 1978 HUD label numbers: Serial numbers:0RFL1A850381557 ADDRESS INFORMATION Current location (including"eity, state, ZIP):4155 LANCASTER DR NE#62 SALEM, OR 97305 County:MARION Manufactured home park Name, if applicable:CHEMEKETA MV ❑ Oregon dealer lot Dealer name: ❑ Out-of-state dealer lot .Dealer name and contact information: Placement location(including city, state, ZIP):3125 ELLIS AVE NE#67 SALEM, OR 97301 County:MARION Manufactured home park name, if applicable:ORCHARD MHP ❑ Oregon dealer lot D aler name: Applicant signature: /dA Amount: Trip permit(per section) $5.00(70511-1195) $5.00 :.TOTAL $5.00 Make check or money order payable to Department of Consumer and Business Services. If paying by credit card,applicant must sign credit card information box. Do not send cash.Secure fax: 503-947-2333 ❑ Visa ❑ MasterCard ❑ Di.yeover Phone:( ) Department use only Cardholder signature Amount Name of cardholder as shown on credit card Credit card number Expiration • sif,DCBS Consumer and . Business Servltes 440-5225(l0/17/CONI)