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IV\6 u 1 n 3 —tv- i;13 ._ <br /> 4 : Manufactured Home Trip Permit Application, <br /> ` :r"'' , .- Department of Consumer and Business Services�v" p .• - <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: Larry Spencer . <br /> Address (including city, state, and ZIP): 605 E 17th Ave, Post Falls, ID 83854 - • . <br /> Phone: 208-660-3339 2 • • - <br /> Eniail:. . .. <br /> - - TRANSPORTER INFORMATION <br /> Name: Larry Spencer encer • -Address (including city, state, and ZIP): same as above <br /> Phone: . <br /> Email: - <br /> HOME INFORMATION <br /> Home ID number(if known): 145181 DMV X-plate number(if known): <br /> Manufacturer: HBNWC Model: Year: 2000 <br /> HUD label numbers: <br /> Serial numbers:'2333 <br /> .. ADDRESS INFORMATION <br /> Current location(including city, state, ZIP): 8822 Umatilla Drive NE, Salem, OR 97305 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(includingcity, state,ZIP): 281 Gregory Street , Priest River, ID 83856 County: Bonner <br /> tY> ) 9 Y Y <br /> Manufactured home park name, if applicable: <br /> [' Oregon dealer lot Dealer name: <br /> Applicant signature: <br /> . Amount: <br /> Trip permit(per section) $5.00(70511-1195) $ 10.00 <br /> :TOTAL: <br /> $ 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 0 MasterCard 0 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 /> its D BS <br /> ' Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />