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:. 00 41,55 Lancaskv NE eo Manufactured Home Trip Permit Application Department of Consumer and Business Services -_ 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. APPLICANT INFORMATION ; ': Name: CHEMEKETA MV Address(including city, state,and ZIP): 4155 LANCASTER DR NE SALEM,OR 97305 Phone:503.362.1281 Email: CHEMEKETAMV@GMAIL.COM . 'TRANSPORTER'INFORMATION Name: SITE INSPECTION SERVICES,LLC Address (including city, state, and ZIP): 2390 ALAMEDA ST.NE SALEM, OR 97301 Phone: (503)375-9440 Email: HOME INFORMATION.; . Home ID number W.known): NA DMV X-plate number(if known): Manufacturer: MODULINE Model: NA Year: 2003. HUD label numbers: Serial numbers: ORE440504 ADDRESS INFORMATION Current location (including city, state,ZIP):1060 ALEXANDER EXT. GRANDVIEW,WA 98930 County: YAKIMA 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):4155 LANCASTER DR NE#62 SALEM,OR 97305 County:MARION Manufactured home park name, if applicable: CHEMEKETAMV ❑ Oregon dealer lot D aler name: Applicant signature: /62G. 'Amount: Trip permit(per section) $5.00(70511-1195) $5.00 '°TOTAL ` ` $5.00 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 WDCBS Consumer and Business Services 440-5225(10/17/COM)