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Manufactured Home Trip Permit Application (,0,1 aq(7\5 <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: 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: Manzo-Garcia, Eulalio <br /> Address(including city, state, and ZIP): 10275 Parish Gap Rd SE Turner OR 97392 <br /> Phone:503-871-0027 <br /> Email: <br /> TRANSPORTER INFORMATION <br /> Name: la preza ent construction co <br /> Address(including city, state, and ZIP):10275 parrish gap rd se turner oregon 97392 <br /> Phone:503=871=0027 <br /> Email: <br /> 'HOME_INFORMATION <br /> Home ID number(if known):,. . 404113 DMV X-plate number(if known): <br /> Manufacturer:S u p re m e Model:70/14 Year:1984 <br /> HUD label numbers:000 <br /> Serial numbers:A7SC23040R <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):181 Factory Rd Sunnyside WA 98944 County:Yakima <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(including city, state,Zly):727 Talbot Rd SE Jefferson OR 97352 se 7 County:Marion <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) $ <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 ❑MasterCard ❑Discover Phone:( ) Department use only <br /> $ <br /> - Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> • iDCBS , <br /> 4 Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />