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C \ecr ,IL.)0.1--ey_A v e 3 <br /> - <br /> Cob ( 5a � <br /> Manufactured Home Trip Permit Application <br /> Department of Consumer and Business Services <br /> J' ' Building Codes Division <br /> • , <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:ROYAL MOBILE <br /> Address (including city,state, and ZIP):4652 AVENS AVE SALEM, OR 97301 <br /> Phone:503-581-7976 <br /> Email:royalmobile@ipgliving.com <br /> TRANSPORTER INFORMATION <br /> Name:SUPERIOR HOME TRANSPORT, LLC <br /> Address (including city,state,and ZIP):PO BOX 1067 JEFFERSON, OR 97352 <br /> Phone:541-327-7805 <br /> Email:ritahartzell@gmail.com <br /> HOME INFORMATION <br /> Home ID number(f known): DMV X-plate number(if known): <br /> Manufacturer:FLEETWOOD Model: Year: a oa a, <br /> HUD label numbers: <br /> Serial numbers:22624-A&B <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):2655 PROGRESS WAY WOODBURN, OR 97071 County:MARION <br /> Manufactured home park name, if applicable:ROYAL MOBILE <br /> "'Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):197 CLEARWATER AVE SALEM, OR 97301 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) $ <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 ❑MasterCard ❑Discover Phone:( ) <br /> Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> tiro DC BS <br /> 1 Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />