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fl). -4 378 153 <br /> pF\ <br /> Manufactured Home Trip Permit Application <br /> I' •F�M�e�.uUx��i OI - <br /> 1• .�" Department of Consumer and Business Services <br /> Building Codes Division <br /> 1-535 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:Miguel Sanchez Eligio, Dainerkis Sanchez Morales <br /> Address(including city, state, and ZIP):21356 Hubbard Cutoff Road NE#37,Aurora, OR 97002 <br /> Phone:503-583-9405 <br /> Email: <br /> TRANSPORTER;[INFORMATION <br /> Name:Trapper's Mobile Home Service Inc <br /> Address(including city,state, and ZIP):18126 S. Palmer Road, Oregon City, OR <br /> Phone:503-631-7392 <br /> Email: <br /> HOME`INFORMATION~, <br /> Home ID number(if known):378153 DMV X-plate number(if known): <br /> Manufacturer:Golden West/Karsten Model: Year:2014 <br /> HUD label numbers:ORE 524390 <br /> Serial numbers:ALB034983OR <br /> ADDRESS INFORMATION .- <br /> Current location(including city,state,ZIP):10851 Ardnt Road NE,Aurora, OR 97002 County:Marion <br /> Manufactured home park name, if applicable: <br /> ❑ Oregon dealer lot Dealer name: <br /> El Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):21356 Hubbard Cutoff Road N , A3urrora, OR 97002 County:Marion <br /> Manufactured home park name,if applicable: <br /> El Oregon dealer lot Deales name: <br /> Applicant signature: ►,�1 ✓"�w��'` <br /> • Trip permit(per section) $5.00(70511-1195) . $ <br /> 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 /> ❑Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> 1nDCBS <br /> Consumerand - <br /> 'Business Services <br /> 440-5225(10/17/COM) • <br />