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I3gg5 <br /> 1�-.--�BAD I 49 Manufactured Home Trip Permit Application <br /> Div nsien Form <br /> Department of Consumer and Business Services•Building Codes Division <br /> DepaRrne<rtof Consumer Mailing address: P.O. Box 14470, Salem, OR 97309-0404 <br /> end 9usiness Services <br /> ]535 Edgewater St.NW, Salem, OR 97304 5225 <br /> Phone: 503-378-4530 • Email:mhods.bcd@dcbs.oregon.gov <br /> Web: mhods.oregon.gov <br /> 4 �' «3. APPLICANT INFORItiIATIN {P/ease <br /> ❑Dealer/seller D Lender ❑Escrovti/title agent ❑Owner/buyer ❑Legal representative <br /> Name: T & L TRUCKING <br /> (Last,First,Middle) , INC Phone: 971-209-5757 <br /> Address: 9874 GOLF CLUB RD SE UNIT 13 <br /> (street or P.O.box) <br /> City: STAYTON State: OR ZIP: 97383 <br /> Email: tandltruckinginc@gmail.com <br /> .`'. ^: R' , _ , r _r 3 TRANSP,ORTEIONFORMATION" ~ L <br /> Name: T & L TRUCKING <br /> (Last,First,Middle) INC Phone: 971-209-5757 <br /> Address: 9874 GOLF CLUB RD SE UNIT 13 <br /> (street or P.O.box) <br /> City: STAYTON State: OR ZIP: 97383 <br /> Email: tandltruckinginc@gmail.com <br /> x.� <br /> t g - 3HOME INFORMATION ;' R N 2 > :_ _ <br /> .:�?�x���Y. x,.�_x 1 ,. -5�_��..- x-Y._x.�.- .., .x.a��` _. .: . ._..,. a�� � .._mac. ��� F..�2_ �_ a���'+, <br /> Home ID(if knowiO: <br /> Manufacturer: PALM HARBOR HOMES Year: 2026 <br /> Current Address: 3737 NE PALM HARBOR DR <br /> City: MILLERSBURG County: LINN State: OR <br /> ZIP: 97321 <br /> Serial number(s): 1 6954-A&B HUD label number(s): <br /> (required rfnen Hoare) <br /> ah lam;_ ; g ,AADDRESSINFORMATION tZ s,.3 <br /> ._�....� �-,-�::,.v:. ��_±_...�. _.,mow",.r= >,�, -s.� -.r -�- t �:� '�- . <br /> Current Address: <br /> City: County: State: ZIP <br /> Manufactured home park name: (If applicable) <br /> ❑Oregon dealer lot 0 Out-of-state dealer lot Dealer name: <br /> Dealer contact information: <br /> Placement location: 14077 DUCKFLAT RD <br /> City: TURNER County: MARION State: OR ZIP 97392 <br /> Manufactured home park name: (If applicable) <br /> ❑Oregon dealer lot 0 Out-of-state dea Dealer name: <br /> Dea er c to• inform< 'on: <br /> Applicant signature: <br /> Amonnt { <br /> Trip permit(per section) $5.00(70511/1195) $ <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 /> ❑Visa 0 MasterCard ❑Discover Phone: DCBS Fiscal use only: 70511/1195 <br /> S <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration date <br /> 440-5225(12/25/COM) Manufactured home trip permit application <br />