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r <br /> D ' 1•2c, 3 • <br /> Manufactured Home Trip Permit Application <br /> V.• °) 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. <br /> APPLICANT INFORMATION <br /> • Name:Frank&Joyce Gubbels • <br /> Address(including city,state, and ZIP): PO Box 1590, Silverton, OR 97381 <br /> Phone: q 7` L2-19- 73 <br /> Email: <br /> TRANSPORTER INFORMATION <br /> • Name: f9'G,C 4 JG�C GGc Ldv <br /> Address(including city, state, and ZIP): 6.3 69 69.3erick Lu lir&: 6, £ee4.- 77:5,1? <br /> Phone: 77/.... g/q_73 -* <br /> Email: <br /> HOME INFORMATION <br /> Home ID number(if known): 284939 DMV X-plate number(if known): <br /> Manufacturer:Skyline Homes Model: Year: 1996 - <br /> HUD label numbers:312690, 312691 <br /> Serial numbers:1591100311A, 1591100311B - .-.. <br /> ADDRESS INFORMATION <br /> Current.location(including city,state, ZIP): 18523 French Prairie Rd, Woodburn, OR 97071 County: Marion <br />• Manufactured home park name, if applicable: <br /> El Oregon Oregon dealer lot Dealer name: <br /> [' Out-of-state dealer lot Dealer name and contact information: <br /> Placement location (including city, state,ZIP): 6369 Cascade Highway NE, Silverton, OR 97381 County: Marion <br /> Manufactured home park name, if applicable:- <br /> ❑ Oregon dealer lot Dealer name: <br /> Applicant signature: F2qi'1.1 4 foci Lt____6(.4“ <br /> Amount: <br /> • Trip permit(per section) $5.00(70511-1195) $10.00 <br /> TOTAL $10.00 <br /> • <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 xi <br /> $ al u)/Cr Q 5 8 q <br /> Cardholder signature Amount <br /> • Name•of cardholder as shown on credit card <br /> Credit card number Expiration <br /> m c�� l,e c� <br /> 4Iia II7- <br /> t� <br /> $DCBS '�Gp <br /> Consumer and <br /> Business Services • <br /> 440-5225(10/17/COM) <br />