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Nof-h Simon ;may S� <br /> QaB 33 � (42bo4co8 <br /> LINA 5 7-735E/ <br /> 4 ia. Manufactured Home Trip Permit Application <br /> t Atm,:?°" " Department of Consumer and Business Services <br /> y~`� 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: 310HD30603D . Year: 2022 <br /> HUD label numbers: ORE 556390, ORE 556391 <br /> Serial numbers: PHH310OR21-14709A, PHH310OR21-14709B <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 /> 0 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): 22823 N SANTIAM HWY, LYONS, OR 97358 County /14420/J <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot ealer nam • ,,,,//pp <br /> Applicant signatur feclat gt.he;I R p�//kW �/r —�j°a GG( <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 ❑Discover Phone:( ) <br /> Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> i <br /> Credit card number Expiration <br /> iiiDCBS <br /> , Consumer and <br /> Business Sewlces <br /> 440-5225(10/17/COM) <br />