Laserfiche WebLink
r (01388 Buyn - St-. S. , SC-tie 7 31-7 <br /> Manufactured Home Trip Permit Application -5(00 c1 <br /> ftto Department of Consumer and Business Services 0,a_nej SD4lo( 4' <br /> • <br /> 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 /> APPLICANT INFORMATION <br /> Name:HOMES DIRECT OF OREGON LLC -MILLERSBURG TANYA ABADILLA, OFFICE ADMINISTRATOR <br /> Address(including city,state,and ZIP):3838 PALM HARBOR DRIVE MILLERSBURG OR 97321 <br /> Phone:541-928-2083 • <br /> Email:TANYA.ABADILLA@HOMES.DIRECT <br /> TRANSPORTER INFORMATION <br /> Name:BENNETT TRUCKING &TRANSPORT <br /> Address(including city,state,and ZIP):409 BIGHAM BROWN ROAD EAGLE PT OR 97524 <br /> Phone:541-879-3444 <br /> Email:yor@bennettig.com <br /> HOME INFORMATION <br /> Home ID number(if known):NEW DMV X-plate number(if known): <br /> Manufacturer:PALM HARBOR Model:310HD30763C Year:2021 <br /> HUD label numbers:ORE 554353, ORE 554354 <br /> Serial numbers:PHH3100R20-14328A, PHH3100R20-14328B <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP):3838 PALM HARBOR DR NE MILLERSBURG,OR 97321 County:LINN <br /> Manufactured home park name, if applicable: <br /> ❑■ Oregon dealer lot Dealer name:HOMES DIRECT OF OREGON LLC <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):6888 BURNETTE ST SE, SALEM, OR 97317 County:MARION <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature:6 / ai he/?1L11`q/4i916.S a eif Ore-S- 2-6' <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $10.00 <br /> 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 ❑MasterCard El 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 /> iii DCBS <br /> Consumer and <br /> BusinessSerriees <br /> 440-5225(10/17/COM) . <br />