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THC1 artyc+-er ANJ -e INr , SjeY-,--Th o b 5 <br /> -' Manufactured Home Trip Permit Application <br /> `' • Department of Consumer and Business Services <br /> • `'9' 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:ROYAL MOBILE <br /> Address(including city,state, and ZIP):4652.AVENS AVE SALEM, OR 97301 <br /> Phone:503-581-7976 <br /> Email:royalnnobile@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(if known): DMV X-plate number(if known): <br /> Manufacturer:SKYLINE Model: Year:Do 3 <br /> HUD label numbers: <br /> Serial numbers:1270-A&B <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):550 BOOTH BEND RD SE MCMINNVILLE, OR 97128 County:YAMHILL <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):176 CLEARWATER AVE SALEM, OR 97301 County:MARION <br /> Manufactured home park name, if applicable: <br /> ❑ Oregon dealer lot Dealer name: 1 <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:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> $ DCBS <br /> ' Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />