337839 - Laserfiche WebLink

Home Browse Search

i`7 a N x Ln . Ch-l--ral i ct \A)p\ I D � �I �; 3 %��; _ , Manufactured Home Trip Permit Application 3? 3 ,,, ,,.. .,,:i Department of Consumer and Business Services n •.., Building Codes Division ( 5 1 II O co- 1535 Edgewater St. NW, Salem,Oregon• Phone: 503-378-4530 • Fax: 503-378-4101 Web: oregon:gov/bcd •Email: mhods.bcd@oregon.gov • This application must be submitted with a valid tax certification from the county in which the home is currently located, ''as well as the county the home is moving to.A valid tax certification is one that has been certified by the county and submitted before the expiration date provided by the county at the time of certification. •APPLICANT INFORMATION ` ' ' Name: J.;(( 0024 Svy- Address (including city,state, and ZIP): '?0.15'0 x( 6 311 - h ui Phone: 503-7O3-5177 Email: j 111..e hi-e cum ea6 r n -)-- TRANSPORTER INFORMATION . Name: Reeves 1 w,ly1 Address (including city,state,an4ZIP): po ao X (q,3 L Vt , R 63,7- Phone: 3(00_G7 „ay0 Email: 'fj I^eede5 c)i e ect5-f-. ne, HOME INFORMATION . Home ID number(if known): • 2 q 1(0,3, DMV X-plate number(if known): Manufacturer: 5 e,4,.1500A Model: Year: '978 HUD label numbers: Serial numbers: fl q 5C(p71 Q.RA 3 . . ADDRESS INFORMATION _ Current location (including city,state,ZIP): k 3o(o M _Oyler j1`G) lt/ood bwrii County: ina,vicri Manufactured home park name, if applicable: ❑Oregon dealer lot Dealer name: ❑Out-of-state dealer,lot Dealer name and contact information: Placement location(including city, state,ZIP): 1 '] a NR x Lyt 1 lih ell 0. 1 -'1 f - County: Manufactured home park name, if applicable: ❑Oregon dealer lot Dealer name: Applicant signature: ie, ) it Aniot `m t• _ Trip permit(per section) 55.00(70511-1195) S /D— 'TOTAL, $ /0 - Make check or money order payable to Department of Consumer and Business Services. If paying by credit card,applicant must sign credit card information box.Do not send cash.Secure fax: 503-947-2333 ❑Visa 0 MasterCard ( ,l Discover Phone:( ) Department use only . (1( Ek-e liort $ )0.00 . Cardho der signature Amount • Name o cardholder as s i vn on credit card W// Dile'7350i 3V7/ L.z__.l Credit card number Expiration • CBS (ensue ei and Baines Sfrvucs 440-5225(10/17/COM)