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94 9 1\1.W A laser S--L m l I a <br /> Manufactured Home Trip Permit Application a4.;_ <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@aoregon.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: f J p rl KV'a.k <br /> vt <br /> Address(including city;state,and ZIP): ( 1 to void Si 9E Sti M en 302,_ <br /> Phone: 140( - 31-SS7 <br /> Email: CfrakyakL'd LAId 4- %" <br /> TRANSPORTER INFORMATION <br /> Name:: } I IftQ <br /> -Address(including city,state,and ZIP): j%( &1(-rye-' Ole uo O7 37 <br /> 441 <br /> Phone:. ?1fl;i. -- -550 1 . <br /> Email: �(lnsi VIqLtP Gl tt.d4 . CAtiI/( <br /> i HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer: %ti,Q((,4.140Dd Model: 46 F(.�'2 tt, 3G Year: 2,025 <br /> HUD label numbers: owe 51,381 l bee, 10.313 <br /> Serial numbers: .�'i :°)ilD bez2-5_ ' ilg5A 21a.0A 25- DOSS <br /> ADDRES INFORMATION • <br /> Current:location'((including city,state,ZIP): 2(p 55 ?rOjr v� 11J& k.Sood'btA t/ County: J 14.110Yj <br /> Manufactured home park.name,"if applicable: cJ <br /> At:Oregon dealer lot Dealer name: CaNt..0 /1cU jc�r( q <br /> ❑Out-of-state dealer lot. Dealer name and contact information: J <br /> Placement location(including city,state,ZIP): V45 A(A) ft(4 '€ County: 14 U1 <br /> Manufactured home nark name,if applicable: "1 <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: ,( ,� <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $ 5 <br /> TOTAL. $ r•'— <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 /> ❑ isa ( MasterCard 0 Discover Phone:(9-m1t44 -3z_8-7 <br /> Department use only <br /> $ 5 <br /> Cardholder signature Amount <br /> 4L S“1, I9d 1 Nt�c.drl <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> 4D BS <br /> } Consumerard <br /> 6ucinusService <br /> 440-5225(10/17/COM) <br />