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a-B 5 Fe r r G SE <br /> Manufactured Home Trip Permit Application <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: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 /> HOME INFORMATION. <br /> Home ID number(If known):NEW DMV X-plate number(if known): <br /> Manufacturer:CAVCO/PALM HARBOR Model:310HD30743F Year: 2026 <br /> HUD label numbers: ORE 570464, ORE 570465 <br /> Serial numbers: CAV3100R25-16746A, CAV3100R25-16746E <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): 21285 FERRY RD SE, STAYTON, OR 97383 County:MARION <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dealer e: <br /> Applicant signature: " A, G� <br /> i <br /> Amoun`t': <br /> Trip permit(per section) $5.00(70511-1195) $ 10.00 <br /> _ <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 /> ❑Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> Oi!DCBS <br /> (onsumerand <br /> Rusinces Scrvitcs <br /> ' 440-5225(10/17/COM) <br />