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Manufactured Home Trip Permit Application <br /> °r ��-•Y M 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: l _P✓l �'�L k-ko1+'-ec CGt�C� 11T(l� � �{� <br /> Address(including city,state,and ZIP): (o �.q by W �-� W <br /> Phone: 5 - ( (o 7-7- <br /> Email: Cc;Lsi . C e AtYc•-k‘Ao vke S�Ck . Cc)ev` • <br /> TRANSPORTEI't'INFORMATION . <br /> Name: <br /> Address(including city,state,and ZIP): C'Q VO -rr k n S <br /> Phone: _t,(\—Colic( —4"Co'i-G <br /> Email: C o}-S -e • C IA C o.k C vv•eA @ O i c'. ; ( , C CP/\" <br /> HOME INFORMATION, <br /> Home ID number(if known): I DMV X-plate number(if known): <br /> Yj�t fodel: I�'PM P ru 504f i 1 Year:DO lk <br /> Manufacturer: ��-'�ti.P.t/�� pa �a�1 <br /> HUD label numbers: <br /> Serial numbers: t C41\3 a LA 4 S 3 a U a 3 <br /> ADDRESS INFORMATION . <br /> Current location(including.city,state,ZIP): mac ‹,u,,Anv,vcte RI Weiser lb County: <br /> Manufactured home park name,if a licable: �_ g <br /> 1.1 a . <br /> Oregon dealer lot f Dealer name: ce,(& cc Ove c 4-14 <br /> C)Out-of-state dealer lot Dealer name and contact information: r ll C .}�JV County:�(a�(tCv1n <br /> Placement location(including city,state,ZIP): T'h-U t J \i c VrI P.1,- Q- t `''� <br /> Manufactured home park name,if applicable: �c q. <br /> 0 Oregon dealer lot I Dealer name: <br /> Applicant signature: - <br /> Amannt: <br /> Trip permit(per section) $5.00(70511-1195) $ 5 co <br /> TOTAL:. $ t j, c,E) <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 /> O. Visa 0 MasterCard ■ I scover Phone:6—(A 5— -- Department use only <br /> i , - _ .CSC) <br /> Cardh• der signature <br /> Amount <br /> mac_ c k �P L. 1 �,�. �-c� <br /> Name of cardholder as shown do credit card ` <br /> (4036GCa1 1556 Li 51 (),O <br /> Credit card number Expiration <br /> 7 BS <br /> Consumer and <br /> BushinsServices <br /> 440-5225(10/17/COM) <br />