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COQ � 5'L <br /> `a -74 a) 1 C Cwb Y <br /> �� -� ����� <br /> • <br /> Manufactured Home Trip Permit Application <br /> Department of Consumer and.Business Services <br /> Building Codes Division <br /> 1535 Edgewater St.NW, Salem,Oregon c Phone: 503-378-4530 o Fax: 503-378-4101 c!rJ <br /> Web: oregon.gov/bcd Email:mhods.bcd(a�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 /> Name: Stephen P.Crook <br /> Address(including city,state,and ZIP): 2151 Three Lakes Rd.SE.#1 Albany,Oregon 97322 <br /> Phone: (541)337=4197 <br /> Email parksidemhcl@comcast.net <br /> Name: Bennett Trucking <br /> Address(including city,state,and ZIP): 1360 Industrial Way Woodburn,Oregon 97071 <br /> Phone: (503)981-7939 <br /> Ernail:wbo@bennettig.com <br /> AT rr. <br /> ®MEIiVEQ36��ti; <br /> Home ID number (if known): DMV X-plate number(if known):. <br /> Manufacturer: Fleetwood Model:Eagle/210EG28483S Year:2019 <br /> HUD label numbers:ORE 545452 /ORE 545453 <br /> Serial numbers: FLE210OR19 19572A / FLE2100R19 19572B <br /> Current location(including city,state,ZIP):1360 Industrial Way Woodburn, Or.97071 County: Marion <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> o Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP): 9874 Golf Club Rd.#79 Stayton,Oregon 97383 I County: Marion <br /> Manufactured home park name,if applicable: Oak Estates MHC LLC <br /> p Oregon dealer lot Dealer name: <br /> Applicant signature: /L <br /> Amount,, <br /> Trip permit(per section) $5.00(70511-1105) $ <br /> TOTAt_4._ $. <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 0 Discover Phone:( ) Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> OP'. S <br /> h ; Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />