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<br /> Manufactured Home Trip Permit Application 6,0 Q �5Oe
<br /> Zi.„ a, -.:etc
<br /> i�• t;{,;*,,,,. gy$ Department of Consumer and Business Services
<br /> Building Codes Division
<br /> 1535 Edgewater St. INV, Salem, Oregon • Phone: 503-378-4530 ° Fax: 503-378-4101
<br /> Web: oregon.gov/bcd A Email: mhods.bcd(a),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 /> 1 APPLICANT INFORMATION
<br /> Nanu::C0/1�?ZOiCt�'f•;lV-tC 1�C ”( tl ,l3.t, �%(
<br /> 1--Ci . > Of:-• —
<br /> Address(including city,state,-)and ZIP) V'LL (.),A .`-,;t- i'_b(.i < .tj-t`'(--t -Int.; .( i)',`_,,>r',17'L.1_ i,c--`11
<br /> Phone: 64t .211V- (_ 14( —_..
<br /> Email: V Cal )a{ '.J f 01 z",. t'•i l-)1.r(,i(;i ti iLa t l al 1\ ',
<br /> ,, TRANSPORTER INFORMATION
<br /> Name: ` -1 •i")..._1 '''r I) .� - \(,h .)(:1 �_._ („-
<br /> Address-(inc city,state, and ZIP) l I L 5 , ,-i,,,,,,c1 ,,:',1,- . -'( clic. .gin c ._1. i::,--/
<br /> Phone: C
<br /> Email: iil VA t Ai 'T-Lt U 'UG\1T)1.\d C (-.I�_f
<br /> > HOME INFORMATION
<br /> Home ID number((f knrnrn): eL )_A.c-1 1—e DMV X-plate number(if known):
<br /> Manufacturcr: .T ''"` ' Model: ; _ l -.:C_4. •— Ye tr: .0
<br /> HUD label numbers:('; , 1 ',!., 46 -i -1 ` ` L. Q L.
<br /> Serial numbers:. ari(y) .aa -a-i-14 .
<br /> ADDRESS INFORMATION
<br /> Current location(including city, state, ZIP): �( �-�( K''i',�"�'j }k�I} ees i LC crti'RL l-fai r�'� 1 County:IR- i
<br /> \(
<br /> Manufactured home park name, if applicable: u1 01 i
<br /> ❑Oregon dealer lot. Dealer name:
<br /> ❑ Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city, state,ZIP): .5-10 E 'v1 beth - _AVe,i 1.V`tr t C)12. I County:c ,o`}('+l
<br /> Manufactured home park name, if applicable: GI-].at a
<br /> ❑ Oregon dealer lot Dealer name:
<br /> Applicant signature: 44 -.
<br /> Amount:
<br /> Trip permit(per section) $5.00(70511-1195) $
<br /> TOTAL $
<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 ❑Discover Phone:( ) � Department use only
<br /> S.
<br /> Cardholder signature Amount
<br /> Vinnie of cardholder.aa shown on credit card
<br /> i
<br /> Credit card number Expiration
<br /> CBS
<br /> L (Qnsunw art{ .
<br /> uts i tss Savkes
<br /> 440-5225(10/17/C M)
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