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-AzL 3 9q5 <br /> BCD I=9 Manufactured Home Trip Permit Application Form <br /> Department of Consumer and Business Services•Building Codes Division <br /> DeparVnentoi Consumer Mailing address: P.O. Box 14470, Salem, OR 97309-0404 <br /> and 6usineu Services <br /> 1535 Edgewater St.NW, Salem,OR 97304 5225 <br /> Phone: 503-378-4530 • Email:mhods.bcd@dcbs.oregon.gov <br /> Web: mhods.oregon.gov <br /> -s. {.•__. `; a s yAt#Et N t.1NFORM#i0Ns Please r itt ••k_ ° - <br /> Dealer/seller ; <br /> ❑ <br /> ❑Lender DEscrow/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 /> ISVA. , -x- ..L x; uT,RANSPORTER INFORMATIONA s e n, _ -r h•. <br /> Name: T & L TRUCKING, INC(Last,First,Middle) Phone: 971-209-5757 <br /> Address: 9874 GOLF CLUB RD SE UNIT 13 <br /> (street or P.O,box) <br /> City: STAYTON <br /> State: OR ZIP: 97383 <br /> Email: tandltruckinginc@gmail.com <br /> 2 }Ste. ,_ _3R ' - ;I,- x HOME Ifd ORNlATION t: ' ;MT z : , r- w , <br /> Home ID(if known): <br /> Manufacturer: PALM HARBOR HOMES Year: 2026 <br /> Current Address: 3737 NE PALM HARBOR DR <br /> City: MILLERSBURG County: LINN State: OR ZIP: 97321 <br /> Serial number(s): 16954-A&B HUD label number(s): <br /> ., : .._-_P�,a. ._�#_ fA:PO:FM S,INFQA:00ION home) . <br /> ,�/r ) <br /> MV <br /> Current Address: <br /> City: County: State: ZIP <br /> Manufactured home park name: (Ifapplicahle) <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• infonm< 'on: <br /> Applicant signature: <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 ❑MasterCard ❑Discover Phone: DCBS Fiscal use only: 70511/1195 <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 />