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, . Ae_i_lf 1 .3 (0+-7 <br /> ' i • Manufactured Home Trip Permit Application <br /> Department of Consumer and Business Services <br /> r.F Building Codes Division <br /> 1535 Edgewater St, NW, Salem, Oregon • Phone: 503-378-4530 • Fax: 503-378-4101 <br /> • <br /> Web: oregon.gov/bcd • Email: mhods,bcd@oregon,gov <br /> • <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:LEVEL LINE CONSTRUCTION • , • <br /> Address (including city, state, and Z1P):2141 COOS BAY WAGON RD ROSEBURG OR 97471 <br /> Phone:541-733-6996 <br /> Email:LEVELLINECONSTRUCTION@OUTLOOK.COM <br /> •. TRANSPORTER INFORMATION <br /> Name:OTT TRANSPORT <br /> Address (including city,state,and ZIP):PO BOX 46 VENETA OREGON <br /> Phone:541-733-6996 ' • <br /> Email:LEVEL LINE CONSTRUCTION <br /> HOME INFORMATION <br /> Home ID number(if known):286323 DMV X-plate number(if known): <br /> Manufacturer':GOLDENWEST Model: Year:1997 <br /> HUD label numbers: . . <br /> •Serial•numbers:GWOR23N17280A-GWOR23N17280B . .. <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP):4355 ROSE BOWL LN SE County:MARION <br /> Manufactured home park name, if applicable: <br /> ❑ Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):550 STATE ST SUTHERLIN OR 97479 County:DOUGLAS <br /> Manufactured home park name, if applicable:MEADOWS MH PARK <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature:RICHARD KORTHOF <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 /> $f DCBS <br /> Consume!and <br /> Business Sery ees <br /> 440-5225(10/17/COM) . <br />