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<br /> -ie.,....,:.. Manufactured Home Trip Permit Application M5? ?�
<br /> s ` y ';z,i Department of Consumer and Business Services
<br /> `�-7!' Building Codes Division
<br /> - 112x
<br /> 1535 Edgewater St,NW, Salem,Oregon•Phone:503-378-4530•Fax: 503-378-4101
<br /> Web: oregon.gov/bcd •Email: mhods.bcd(ci?,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. 1
<br /> AF LI.CANT INFORMATI,OIV yl < , ,� :1 r, a.",._..al>?
<br /> Name: J'.1'rv1 1`1.0 LLC.
<br /> Address(including city,state,and ZIP): I o2gU I s � �� fti�U�)J _c � too) Cl cc aril tdR9�) 4
<br /> r
<br /> Phone: 5o5-'909.-5'I(ph
<br /> Email: i3 01A"-t1 7,X3.CJ V1'l .�/1d09 $. clDP►')
<br /> P J,
<br /> mss-'---A—N—'SPORTER=IN RMATION _ ., � �'� i �'N- i
<br /> Name:S`1-' 1,'kitt�- ;4 LLL, o , "- �,` 1
<br /> Address(including city,state,and ZIP): I ..9-() L a f /7 th e} 5u67 C tori Q.J.a�'.c- .&ma" C? .9"7cJ
<br /> Phone: Q-5 --903_j"/ CQ/j I.
<br /> Email a,rtn oonwe L d LI v n,co Coi'1
<br /> :HOME`IN.F.ORMATION ',
<br /> y 5y a" i.
<br /> Home ID number(if known): QJ \its DMV X-plate number(if known):
<br /> Manufacturer:C,, }- Model: 7 a p/{in 2.q36,2,19-0/ Year: 2)1 y 1
<br /> HUD label numbers:
<br /> Serial numbers: /1 ;10 0► i AL, r 37.7 0 i
<br /> ,:.:,.......,1, ,. . . .,..:..AO 0.'ESS'. FORMATION-
<br /> Current location(including city,state,ZIP): p,441.5p,441.5pact:FtC g(1,4 6COy Alb a'rt/ OR 97 �jCounty: 1.4 kw) i
<br /> Manufactured home park name, if applicable: , /
<br /> ❑Oregon dealer lot 1 Dealer name:
<br /> 0 Out-of-state dealer loll Dealer name and contact information:
<br /> Placement location(including city,state,ZIP):7156 .Ile-ill a Wa Loop N_C, 4. Lto r 404 9Z Oounty: &bri&
<br /> Manufactured home park name,if applicable:'g a u'!b(J(3 G a.rt•k vi /fd f a k Oil l leyC 1.1.,C. ,
<br /> 0 Oregon dealer lot Dealer name:
<br /> Applicant signature:6*(74 $,,r1
<br /> fig Aiadnt c_
<br /> Trip permit(per section) $5.00(70511-1195) $ j`
<br /> ;. ,i '; .,,_,f azo `,s r TOTAL;.< $
<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 /> 0 Visa 0 MasterCard 0 Discover Phone:( ) Department use only
<br /> $
<br /> Cardholder signature Amount
<br /> Name of cardholder as shown on credit card '
<br /> Credit card number Expiration
<br /> cjLL.' CBS i
<br /> j®
<br /> (cnsumcr and
<br /> BusinessSenkes
<br /> 440-5225(I0/17/COM)
<br />
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