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\is qubvLn <br /> Manufactured Home Trip Permit Application <br /> PArktrA <br /> *.e",;77., •.-7 Department of Consumer and Business Services ork icto <br /> Building Codes Division <br /> NI.• 544-7.28, <br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530 • Fax: 503-378-4101 <br /> Web: oregon.gov/bcd • Email: mhods.bed@orcgon.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:I& L TRUCKING,:.INC .._ • <br /> Address (including city,State, and ZIP):9874 GOLF CLUB RD SE UNIT 13 STATYON, OR 97383 • - • <br /> Phone;9717209-5757 <br /> Email:tandltruekinginc@Omail.com <br /> TRANSPORTER- INFORMATIONName:T&L TRUCKING, INC, <br /> Address (including city,state, and ZIP):9874 GOLF CLUB RD SE UNIT 13 STATYON, OR 97383 <br /> Phone:971-209-5757 <br /> Email:tandltruckingine©g mail.corn <br /> HOMEINFORMATION <br /> Home ID number(if known): DM\'X-platc number (if known): <br /> Manufacturer:SKYLINE Model: Year:2025 <br /> HUD label numbers: <br /> Serial numbers::2201-A8;:t3 • „ , <br /> Current location(including city,state,ZIP):550 SW BOOTH BEND RD MCMINNVILLE, OR 97128 County:YAMHILL <br /> Manufactured home park name, if applicable: <br /> '0,0regOn.dealer lot Dealer name: <br /> El Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):11592 WARBLER LN NE AURORA, OR 97002 County:MARION <br /> Manufactured home park name, if applicable: <br /> El Oregon dealer lot Dueler name: <br /> Applicant signature: . <br /> Trip permit(per section) $5.00(70511-1195) S <br /> VanWVWP'VqtiWigWagiaMi*':TbtAttql $ <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 /> D Visa E]MasterCard D Discover Phone:( ) Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> 7-1': oil BS <br /> Consuaitt and <br /> ButtnesServites <br /> 440-5225(10/17/COM) <br />