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<br /> Manufactured Home Trip Per Application M 3 5 E 30-7
<br /> k )epartment of Consumer and Business Services
<br /> °••: '' r.:uilding Codes Division
<br /> 1535 Edgewater St.NW,Salem,Oregon o Phone:503-378-4530*Fax:503-378-4101
<br /> Web: oregon.gov/bcd o 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 /> • APP( (GAIT"8 FO I,'TOOK ,,, .
<br /> , � r
<br /> Name: Ce*-cc:...k l-Anvv,-QS
<br /> Address(including city,state„and ZIP): C aC. .) '„J E --;Am � `)c,( f Ve. i , d L�`
<br /> Phone: i -SCI q- �:toi-tc l, q -.c',
<br /> Email: e45,,e_ . (e v-v- `c o.1 i-ko eS rC-- V\-Ku-a,C.ov1/4- .
<br /> Name: 0 Va
<br /> Address(including city,state,and ZIP): [n aei j �� �c�wcock*lie. aa. 6
<br /> Phone: $54\—C�et et_3-C e(
<br /> Email: St'e • Cev 1novk,`eSeNVV + -i,.l , COv
<br /> HOME 6Nfi tRIVIAT101
<br /> Home ID number(if known): N r‘Af DMV X-plate number(if known):
<br /> Manufacturer: prf,, c to /C lao_kil.k.i6 i OSA Model: Pr 9"'two, .`h E L 1) Year: ao l
<br /> HUD label numbers:
<br /> Serial numbers: I C.,113 a Lk LA : g-, .Lk a:3
<br /> A111 DRESS.INFORMATION
<br /> Current location(including city,state,ZIP): tuac S:t,v.k,. Si cls (i).(:,,, ,,,, ale,. County:
<br /> Manufactured home park name,if applicable: 3 G-f-a
<br /> ,; -Oregon dealer lot Dealer name: ca(ce. . d s E41-( c_- ().l
<br /> ❑Out-of-state dealer lot Dealer name and contact information: _
<br /> Placement location(including city,state,ZIP): an l.J tk\Aiox S{ i;'I; (i".1-4,. County
<br /> Manufactured home park name,if applicable: n R .." cd i- )
<br /> ❑Oregon dealer lot Dea er name: •
<br /> Applicant signature: ' CCreTh _ ,
<br /> OQ n laced a- '7 8 0 N w. A-icier 34. rn.i It Ci 4.1 0 R R`73(60 -amoaa a
<br /> 5P _
<br /> Trip permit(per section) $5.00(70511-1195). $ 5 c tz7
<br /> Make check or money order payable to Department of Consumer and Business Services.If paying by credit card,applicant
<br /> mustsigncredit 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 /> ?
<br /> 1xp9n
<br /> -)'C8S
<br /> ",,,z Consumeraad
<br /> SusmessServices
<br /> 440-5225(10/17/COM)
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