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I a a 3 13 5ti 1 verk)v\ R j . <br /> ME Si tvcrlort <br /> : , Manufactured Home Trip Permit Applicationg Department of Consumer and Business Services r, <br /> 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:HOMES DIRECT OF OREGON LLC-MILLERSBURG TANYA ABADILLA, OFFICE ADMINISTRATOR <br /> Address(including city,state,and ZIP):3838 PALM HARBOR DRIVE MILLERSBURG OR 97321 <br /> Phone:541-928-2083 <br /> Email:TANYA.ABADILLA@HOMES.DIRECT <br /> TRANSPORTER INFORMATION <br /> Name:BENNETT TRUCKING &TRANSPORT <br /> Address(including city,state,and ZIP):409 BIGHAM BROWN ROAD EAGLE PT OR 97524 <br /> Phone:541-879-3444 <br /> Email:yor@bennettig.com <br /> HOME INFORMATION <br /> Home ID number(if known):NEW DMV X-plate number(if known): <br /> Manufacturer:PALM HARBOR Mode1:310HD30633F Year: 2024 <br /> HUD label numbers: ORE 562989, ORE 562990 <br /> Serial numbers: PHH3100R23-15829A, PHH3100R23-15829E <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP):3838 PALM HARBOR DR NE MILLERSBURG,OR 97321 County:LINN <br /> Manufactured home park name, if applicable: <br /> 0 Oregon dealer lot Dealer name:HOMES DIRECT OF OREGON LLC <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP): 12213 SILVERTON RD NE, SILVERTON, OR 97381 County:MARION <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot ler name• ai <br /> Applicant signat <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) • $ 10.00 <br /> TOTAL , $ 10.00 <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 /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> MDCBS <br /> Consumer and <br /> `• "Business Services <br /> 440-5225(10/17/COM) <br />