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.. <br /> ' a a ( -zi N I Dirl-k So-v.)4)-(1-n-) w sL2 r LY ° n 5 ' ' <br /> Wiz.: Manufactured Home Trip Permit Application <br /> ,W.? 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 61131 , <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:HOMES DIRECT OF OREGON LLC-MILLERSBURG TANYA ABADILLA, OFFICE ADMINISTRATOR <br /> 'Address(including city,state,and ZIP):3838 PALM HARBOR DRIVE MILLERSBURG OR 97321 <br /> Phone:541-928-2083" <br /> Email:TANYA.ABADILLA©HOMES.DIRECT <br /> `-' TRANSPORTER.INFORMATION, , _' <br /> Name:BENNETT TRUCKING&TRANSPORT <br /> Address(including city,state,and ZIP):409 BIGHAM BROWN.ROAD EAGLE PT OR 97524 "" <br /> Phone:541-879-3444 <br /> Email:yor@bennettig.com <br /> : . <br /> HOME INFORMATION <br /> Home ID number(if known):NEW DMV X-plate number(if known): <br /> Manufacturer:PALM HARBOR Model:310HD30763H Year: 2026 <br /> I-HiD label numbers: ORE 568424, ORE 568425 <br /> _ <br /> Serial numbers: CAV3100R25-16564A, CAV3100R25-16564B <br /> °ADDRESS',=INFORMATION <br /> Current location(including city,state,ZIP):3838 PALM HARBOR DR NE MILLERSBURG,OR 97321 County:LINN <br /> Manufactured home park name,if applicable: <br /> ❑� Oregon dealer lot Dealer name:HOMES DIRECT OF OREGON LLC <br /> ❑Out-of-state dealer_lot Dealer name and contact information: <br /> Placement location(including city,state, ZIP):22614 N SANTIAM HWY SE, LYONS, OR 97358 County:MARION <br /> Manufactured home park name,if applicable: <br /> El Oregon dealer lot D r ame: <br /> Applicant signature: /C,Z, L, <br /> Amount:' <br /> Trip permit(per section) $5.00(70511-1195) $10.00 <br /> . . . . „ , -TOTAL'::';, $ 10.00 <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 /> Credit card number Expiration <br /> *DCBS <br /> Consume!and <br /> Business Services <br /> 440-5225(10/17/COM) , <br />