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• <br /> 0ojuococt Dr. � c -e� 5 � 5 60013oa <br /> Manufactured Home Trip Permit Application <br /> 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: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 Mode1:3104G28563B Year: 2023 <br /> HUD label <br /> abe1 numbers: ORE 559375, ORE 559376 <br /> Serial numbers: PHH3100R22-15127A, PHH310OR22-152718 <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 /> III 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): 157 DOGWOOD DR, GATES, OR 97346 County:MARION <br /> Manufactured home park name,if applicable: <br /> ❑ Oregon dealer lot Dealer name: <br /> Applicant signature <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 /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Expiration <br /> Credit card number Ex P <br /> ii :DCBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />