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5 X13 5 5441
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<br /> 0',,Lr . Manufactured Home Trip Permit Application
<br /> 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 /> i i Z s 3-ClL �1i Y f y.. �w if t+y ., x+r�;'F' i
<br /> i. .` ,r, .M,: `,,./ tete GANANNFORIMATfOR K:to , 5 a_,_ `�.:� O,.,,>. .. -.. _ li
<br /> Name:Tce/yi liv N12 5 t..C. I
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<br /> Address(including city,state,and ZIP): I R.96/ sE 97 .A- e 131mi e,, /cC)1.C 1 Lk?..`'a e,5,d R 97615
<br /> Phone: 5O —90.2 — l 62(p
<br /> Email: a owe. ga ie home.-7, o.
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<br /> .: :.:.... �--;-R--A�NSPQRTER�INFORMAT}ION:. : : :.. 4„
<br /> Name:'"** 1 C )!►'1P 5 LL
<br /> Address(including city,state,and ZIP): {g 901 5 E 97111 A'-ve is(,(,t`if 11001 (Li o ck,a ma-5; OR 977015 ,
<br /> Phone: 103-90V-Y16
<br /> Email: a PO q-►.l.0 i viz vvihumQ . COr►-1
<br /> . . ..:.::..
<br /> ,_:..-. .....,-. ..:; -.=:HOME INRORMA ::>,:,.::..;. > - � J
<br /> Home ID number(if known): NEW DMV X-plate number(ifknown):
<br /> Manufacturer: Ciy) / Model:7Q R 5 2 x54/2.-tf l ,'Year: 2O/ ' .
<br /> HUD label numbers: (�
<br /> Serial numbers: Ai,13`J -3 7 �' d 7}, M,.0 � 37.,1., '1 Pg r1
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<br /> ,,- , ADDRESS: NF,ORMATION 4 .�;, t0 �..
<br /> Current location(includin_ cit ,state,ZIP): 4 Ct iC 1 .1 5 . : rt 4 .: U Count : Li rrV1
<br /> Manufactured home park name, if applicable:
<br /> ❑Oregon dealer lot Dealer name;
<br /> 0 Out-of-state dealer lot Dealer name and contact information: . _ 3( `1 G
<br /> Placement location(including city,state,ZIP):.i C 3 W n¢¢. t, d PI. Nt.) 5e,tarn OR I County: fqa/rWY)
<br /> Manufactured home park name,if applicable:
<br /> 0 Oregon dealer lot Dealer natne<
<br /> Applicant signature: {' jA )6,1jvYl;ii '
<br /> tj.rt l.,:*40t ;1i
<br /> • Trip permit(per section) $5.00(705 .1-1195), $
<br /> ' ' TQTAL $
<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 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 /> 1
<br /> I
<br /> 1�!DCBS
<br /> ., Consumer and
<br /> Business swims
<br /> 440-5225(10/17/COM)
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