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. <br /> • <br /> • <br /> e''7.?.. ..Manufactured Home Trip Permit Application <br /> ""� ` Department of Consumer and Business Services _. <br /> 1. <br /> `0 l Building Codes Division <br /> 1535 Edgewater St.NW,Salem,Oregon•Phone:503-378-4530•Fax:503-378-41011 4( 74 <br /> Web:oregon.gov/bcd•Email:mhods.bed@oregon.gov ' <br /> .:This- - <br /> application must be <br /> pp submitted with a valid tax certification from the coup in which the home is located,.-- • <br /> �' currently <br /> as.well as the county the home is moving to.A valid tax certification is one that has been certified bythe county and_.-. <br /> submitted beforeµ the expiration date provided by the county at the time of certification. <br /> APPLICANT INFORMATION <br /> .•Name:. ....°n d';,he IN•t rr•o+.-4a aal2A S 1i.e.ri44., i •ot,0r1 ko ruto.- <br /> Address(including city,state,and ZIP): 940 s elh��tda,,, _ . <br /> Phone: sew—Sol, • <br /> Email: • -‘(n,04 t ct4,.w 41e...aho t,(ou+i.oa gikO�7�tn},4.Cc. e. � <br /> TRANSPOI ER INFORb AI <br /> •Name: C yan._ TN-exitF$130e <br /> Address including city,state,and ZIP) 'Yog Ae lasdMtR�WA �f (ap+, br•Q7S34t <br /> ? `"7 <br /> Phone: • <br /> R'9 S4 f% <br /> Email: ye,c 0 62.yt n.ez4-t t 4 .•Ce m . <br /> HOME INFORMATION . - <br /> Home ID number Of known): S ete ice,46, DMV X-plate number(if known): <br /> Manufacturer: ?al <br /> N 41a tin 14nw1nA Model: Aga- 3 tea,Aa f'e,'a'3 Year: Y <br /> HUD label numbers 0 rt 0 54/q rf 9 8 R i;•At Ysn . <br /> •Serial numbers: �� ei 4._ A.*3 . <br /> ADDRESS INFORMATION ' <br /> Current,location-.(including city,state,ZIP): 5 fis roil 4* .7 u..).�s,t•.•taB l o&bawl pi-County: u- mean <br /> Manufactured home park name,if applicable: <br /> El Oregon dealer.lot Dealer name: ' <br /> ❑Qut=of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP): 17$ b S�Year 1 s.c.„14.5 rn nit.,k,be, County: 11,1 o!.r i or), <br /> Manufactured home park name,if applicable: (17W-15 <br /> 0 Oregon dealer lot Dealer name: <br /> Applicant signature I_2,,.�,� <br /> Amount: <br /> • Trip permit(per section) $5.00(70511-1195) .5 to. • <br /> TOTAL. $ t o <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 /> ❑ 0 MasterCard ❑Discover Phone: o .`t o <br /> (Sod 5 x o8 <br /> Department use only <br /> _ P <br /> ( i.�s v.,. $ l b.ep . <br /> Cardholder signature Amount <br /> Nam:of cardholder as shown on credit card <br /> A011.111. <br /> • <br /> Credit card number Expiration <br /> itiDCBS <br /> • (OMulnadad <br /> Businetf krrkes <br /> 440-322S(t0n7tCOM) <br />