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In 16 19, 02:25p Dougs Mobile Home Service 503-200-1299 p.1 <br /> erne_ e St-046 ULY,ig Manufactured Home Trip Permit Application t� 3S 1 ( Z3 <br /> `' Department of Consumer and Business Services <br /> :--::..; P <br /> i_ Building Codes Division <br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530•Fax: 503-378-41.01 <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:Brian Fritterer inc <br /> Address(including city, state,and ZIP):18006 Sky Park Circle STE 200 Irvine CA 92614 <br /> Phone: <br /> Email: <br /> TRANSPORTER INFORMATION <br /> Name:Dougs Mobile Home Semrice INC/Doug Walton <br /> Address (including city, state, and ZIP):12692 Fry rd Aurora OR 97002 <br /> Phone:503-799-0539 <br /> Email:d ugwalton @aol.com <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Skyline Model: Year:2018 <br /> HUD label numbers: <br /> Serial numbers:2f-91-0342-I-a 2f-91-0342-I-b <br /> - ADDRESS INFORMATION <br /> Current location(including city,state, ZIP):550 Booth Bend rd Meminville OR County:Yamhill <br /> Manufactured home park name,if applicable:Windemere <br /> ❑Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):646 Windemere ST se Aumsville or 97325 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑ Oregon dealer lot , Dealer name: <br /> Applicant signature: <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) _ $2 <br /> TOTAL $10 <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 /> El Visa sterCard ❑Disc ver Phone:(503)799-0539 Department use only <br /> t holder si mature Amount <br /> Doug Walton <br /> Name of cardholder as shown on credit card <br /> 4802137088004256 Q4 !23 <br /> Credit card number Expiration <br /> CBS <br /> Consume,and <br /> Business Services <br /> 440-5225(10/17/COIR) <br />