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4 Manufactured Home Trip Permit Application <br /> ...y.tz Department of Consumer.and Business Services <br /> �T� 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 /> i APPLI CAN T`INFORMATION . ., , , f: ,, '' <br /> Name:Martin Dunn <br /> Address(including city,state,and ZIP):2390 Alameda ST NE Salem OR 97301 <br /> Phone:503-991-1808 <br /> Email:Larrydunn06@yahoo.com <br /> e TRANSPORTER INFORMATION _` {: , <br /> Name: Martin/Site Inspection Services LLC <br /> Address (including city,state,and ZIP):2390 Alameda ST NE Salem OR 97301 <br /> Phone:503-991-1808 <br /> Email:Shemardunn@aol.com <br /> ?, HOME INFORMATION , . <br /> Home ID number(if known):264584 DMV X-plate number(if known): <br /> Manufacturer:Skyline corp Model:Oak Manor 5700-B ''ear:1990 <br /> HUD label numbers:198724, 198725 <br /> Serial numbers:0691-0434-D <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):5853 silverton RD NE Salem OR 97305 County:Marion <br /> Manufactured home park name,if applicable: 1 <br /> ❑Oregon dealer lot Dealer name: <br /> ❑ Out-of-state dealer lot Dealer name and contact information: 1 <br /> Placement location(including city,state,ZIP):2365 Hawthorne AVE NE Salem OR 97301 Coup.' <br /> Manufactured home park name,if applicable: <br /> El Oregon dealer lot a name: <br /> Applicant signature: � <br /> AMP.unt._= <br /> Trip permit(per section) $5.00(70511-1195) $5 <br /> ', TOTAL $10 <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 ❑ a rd El Discover Phone:5( )991-1808 Department use only <br /> $10.00 <br /> Cardho der signature Amount <br /> Site inspection svc Ilc <br /> • <br /> Name of cardholder as shown on credit card <br /> 4802073000318013 01 /28 <br /> Credit card number Expiration <br /> vtDCBS <br /> Consumer and <br /> Business Servkes <br /> 440-5225(10/17/COM) <br />