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1 �7 (15 Bria13E Ttirne <br /> BCD I gve'sne Manufactured Home Trip Permit Application Form <br /> Cedes <br /> -.onDepartment of Consumer and Business Services•Building Codes Division <br /> Departments Consumer Mailing address: P.O. Box 14470, Salem, OR 97309-0404 5225 <br /> and Business Services 1535 Edgewater St.NW, Salem, OR 97304 <br /> Phone: 503-378-4530 • Email: mhods.bcd@dcbs.oregon.gov <br /> Web: mhods.oregon.gov -1 a 61°37 <br /> APPLICANT INFORMATION (Please print) <br /> ❑Dealer/seller ❑Lender ❑Escrow/title agent ®Owner/buyer ❑Legal representative <br /> Name: Herman, Gayle, Lavonne Phone: 503-510-0558 <br /> (Last,First,Middle) <br /> Address: P.O. Box 903 <br /> (street or P.O.box) <br /> City: Aumsville State: OR ZIP: 93725 <br /> Email: aprllavonne@gmail.com <br /> TRANSPORTER INFORMATION <br /> Name: <br /> (Last,First,Middle) Bentlevel Phone: 503-650-5883 <br /> Address: <br /> (street or P.O.box) P.O.Box 95 <br /> City: Molalla State: OR ZIP: 97038 <br /> Email: office@bentlevel.com <br /> HOME INFORMATION <br /> Home ID(if known): 192755 <br /> Manufacturer: Marlette Year: 1966 <br /> Current Address: 2200 Lancaster Dr SE#9D <br /> City: Salem County: Marion State: OR ZIP: 97317 <br /> Serial number(s): F12260FLE601 1 1 HUD label number(s): <br /> ,w e <br /> (required if new home) <br /> ADDRESS INFORMATION <br /> Current Address: 2200 Lancaster Dr SE#9D <br /> City: Salem County: Marion State: OR ZIP 97317 <br /> Manufactured home park name: (If applicable) Sundial Ranch <br /> ❑Oregon dealer lot ❑Out-of-state dealer lot _ Dealer name: <br /> Dealer contact information: <br /> Placement location: 12795 Brick RD SE <br /> City: Turner County: Marion State: OR • ZIP 97392 <br /> Manufactured home park name: (If applicable) <br /> 0 Oregon dealer lot 0 Out-of-state dealer lot Dealer name: <br /> Dealer contact information: <br /> Applicant signature: <br /> Amount: <br /> Trip permit(per section) $5.00(70511/1195) $ 5.00 <br /> TOTAL $ <br /> Make check or money order payable to Department of Consumer&Business Services.If paying by credit card,applicant <br /> must sign the credit card information box.Do not send cash.Do not email.Secure fax for credit card payments: 503-947-2333 <br /> M Visa ❑MasterCard ❑Discover Phone: 503-510-0558 DCBS Fiscal use only: 70511/1195 <br /> $ 5.00 <br /> Cardholder signature Amount <br /> Gayle L Herman <br /> Name of cardholder as shown on credit card <br /> 4477 6600 1525 1439 10 /26 <br /> Credit card number Expiration date <br /> 440-5225(12/25/COM) Manufactured home trip permit application <br />