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.4co 5 sweS l� kok mb ' 5 a' plc ' :;-,'•, Manufactured Home Trip Permit Application • ° , , Department of Consumer and Business Services A CJ GoO(052/. • '% Building Codes Division 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. . . ter- V - .. ` .1 . ., 7�-_ _ _ . r_. _ ..:.,,,...:L....... G.-ANT I NFO . T ON , �_ v.�_c.. . _. _: Name: 'Gu;h Waco( Address(including city, state,and ZIP): 3737 oS 41 re,Q N ) .we), dye y73a11 Phone: 563 5-57/ $37? Email: al/ fo s re', aQ c m e4SiL, Imo' i TRAN SPO1 TRIN Og Tlbl e" k . Name: S',per tor I vrt Address(including city, state, and ZIP): 2 si /( vel O.-cc-Fob's a.7 OR 5/7 3✓5.2 Phone: n 3 Sri 3 gS'tf Email: Gwr d��es us e 5 agog ror rsO 4 G i!t rse • Co 77 Home ID number(if known): N E DMV X-plate number(if known): Manufacturer: lipmela;Me, find awn_ Model:4't a/3 A Year: 9 7 HUD label numbers iee -33 p/ z 9' j pg8.,3 3®/2,, Serial numbers:Otis') p8 i'1gq A OR NNB m+m8q$ O r' `. AffR ORI 0:10 :,',_7_ :l 7V. .. .µ.... ..1 y. 7 Current location(including city,state,ZIP): if?/5 Sc.,c�,lc Rd NE. ' County: ' Manufactured home park name,if applicable: Scans-4 Y%l4yr ❑Oregon dealer lot Dealer name: El Out-of-statedealer lot Dealer name and contact information: � �"11 gomde Placement location(including city,state,ZIP): 30 30o S,jr y, %# re d+�' County: f Manufactured home park name,if applicable: ❑Oregon dealer lot Dealer name: Applicant signature: 7----'..—_ Lddroof _. Amautfi n Trip permit(per section) $5 00(70511-1195) $ /0,00 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 ❑MasterCard ❑Discover Phone:( ) _ Department use only $ Cardholder signature Amount Name of cardholder as shown on credit card Credit card number Expiration _; (unsumerand Business Services 440-5225(10/17/COM)