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; 9 51 N .‘k) .A‘ a-er Sf . rn ; 11 ci%ty <br /> ,47,Z44 Man! f., et! red Home Trip Permit Application 4 ip i D 4 a? <br /> Department of Consumer and Business Services <br /> ••:-:)::.# Building,Codes Division <br /> 1 D35 Edgewater St.NW, Salem,Oregon 4,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, on 144/41--1- 'CA(15-1-rviL-41 o vt <br /> Address(including-city,state,and ZIP): poft,0 LI i( 14(pi(p MIA.Key cl A 1 s+ % sa,t„Qm tin 30 2, _ <br /> Phone: 0 .-q 10( - 3'ig-i , <br /> Email: CAKYtur-i- eAvtceat-.rkszt <br /> TRANSPORTER INFORMATION <br /> Name: 12 IA.). H-AAA II <br /> Address(including city, state, and ZIP): 1?,:gLe%1 el bucae.n. 9 K.- SC-I Cli 3-1/4 <br /> Phone: TO;fil SI - 434 --550 i <br /> Email: Mk,f2. .111-tli-i? Z 901100 . CAM. <br /> HOME,INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer: •Rej/A-1460d Model: j b pi.,{'2..g L- 3314 , Year: 2,0 25 <br /> HUD label numbers: Ma 51.0-115 I Die_,G., 101.794 <br /> Serial nuinbers: lA 0 be./2.5- 7)1155 A 2i 1:11, I) 0 R 25 - 2,14-75 s e) _ , <br /> ADDRESSINFORMATION <br /> •Current location(including city,state,ZIP): '2i s 5 Fro jregyi VC) tAid..9 000dba_lirl County: A/14,1/M <br /> Manufactured home park name,if applicable: <br /> . <br /> p...Oregon dealer lot -,Dealer name: C6cvc_o illitUNIRAdAy(1 i45 COLKiretf---F" eg14.5-fruLdiael <br /> 0 Out-of-state dealer lot Dealer name and contact information: . <br /> Placement location(including city,state,ZIP): • i5i AfiAJ 6-leteY St Mit( Cali County: Li 411,i1 <br /> Manufactured home park name,if applicable: <br /> El Oregon dealer lot Dealer name: <br /> Applicant signature: jscmA,,,e. 64...e...1-. <br /> Amotint. '-' <br /> Trip permit(per section) $5.00(70511-1195) $ 6-— <br /> TOTAL $ g— <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 /> fisa ctj MasterCard 0 Discover l'hone:(9-6)000 -32_8-1 Department use only <br /> 0i <br /> oft- e/fhAreil , $ 5 -- <br /> Cardholder signature Amount <br /> ne.11 5S A- fed 1 IllitAA,1 <br /> Name of cardholder as shown on credit card <br /> 514M- DO 21/9 D Die/ 30-n 9 / 2..? <br /> Credit card number Expiration <br /> NDCBS <br /> I, •Buflnrseletired <br /> , s <br /> 440-5225(10/17/COM) <br />