|
. ...
<br /> b„rd-
<br /> ,.,',,, ,,k, „ ,...Manitfactured Home Trip Permit Application
<br /> . _ .
<br /> .,,.,---"_-.4.,..,_.it
<br /> , -
<br /> Department of Consumer and Business Services
<br /> Building Codes Division
<br /> 1535 Edgewater St. NW, Salem, Oregon•Phone: 503-378-4530•Fax: 503-378-4101
<br /> Web::Toregon.gov/bcd •Email: mhods.bcd@oregon.gov • ,
<br /> This application must be submitted with a valid tax certification froth tlie-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 /> *.?,P'41.PANTINFQRIVIATION';::-.,_::,..-,...
<br /> , . . . .. „.
<br /> ..1\1gtle:;I:and M Homes.:.
<br /> - .
<br /> H...Addi*s(irielucling eity.,- tate,and ZJP):15815 S Pope Ln Oregon City, Or-97045
<br /> : Ph:one:503=908-8967 7 ' - _ .
<br /> ,
<br /> .':-.. Erimq; gleser/icecicOjandrnhomes.corn
<br /> ' :;;•:'''''.;*::=',. '..1-.''.:''''.:"-;.":-:`,.'-'.:f:7i.:.,7-;::':-:::::'....:•";.:1,1.;:,' ' '''. IRAN gPQR:TER)NFQkIVIATI.ON'-
<br /> .. , Narne:Sarne-.asAbove,:-- - '
<br /> . ,
<br /> •
<br /> Addresi--(ineltiding city;-Sfate, and ZIP): - - .
<br /> ' 'Phone: - - - • --: -. -
<br /> Email:
<br /> -• . - '
<br /> '2.•.,!.':.....',.' '' 4-:;`,.'.1.," ;',:.;•-',', .. '5,'.',•.•::', f-,,-;' :: . '' HOME INFORMATION
<br /> Home ID number(if/mown): DMV X-plate number(y.known):- •
<br /> , . • : ,
<br /> Manufacturer:Golden West-Albany Model:DRM 385A Year:2025
<br /> HUD label ritimbers:-:
<br /> Serial nunibers'.ALB9443300RAB
<br /> ADDRESS INFORMATION
<br /> . .
<br /> -CitrrentiOati0)1(it10114.jitig dity,state,ZIP):2445 Pacific Blvd SW Albany Or 97321 County:Linn
<br /> Manufactured home park name, if applicable:
<br /> E Oregon'dealer lot.,- Dealer name:
<br /> El Out-of-state dealer lot_ Dealer name and contact information:
<br /> ,---PlabernefitlareatiCp(ineRiding citY, state,ZIP):4459 Locust St Spc#60 Hubbard, Or 97032 County:Marion
<br /> Manufactured home park name, if applicable:
<br /> 0 Oregon dealer lot D ! r name:
<br /> a A0Plicntsigpatur • a1 ate I
<br /> ...
<br /> Trip permit(per section) $5.00(70511-1195) $
<br /> 4TOTAL',.,`,..7'.:. $ ,
<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 /> El Visa El MasterCard El Discover Phone:( )
<br /> Department use only
<br /> ... $
<br /> Cardholder signature Amount
<br /> Name of cardholder as shown on credit card
<br /> . _.. /
<br /> Credit card number Expiration
<br /> DCBS
<br /> , Consume:and
<br /> -.,... Business Services
<br /> 440-5225(10/1 7/COM)
<br /> . .
<br />
|