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12219, 02:03p Dougs Mobile Home Service 503-200-1299 1v.. p.1 <br /> 5355 R% 4er RI)�� k) . 35 <br /> Manufactured Home Trip Permit Application I��e; e/.- <br /> M <br /> it*,.., Department of Consumer and Business Services <br /> rsO: <br /> '-' Building Codes Division <br /> k 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-3784530 •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:Doug Walton <br /> Address (including city,state,and ZIP):12692 Fry rd Aurora OR 97002 <br /> Phone:503-799-0539 <br /> Email:dugwalton@aol.com <br /> TRANSPORTER INFORMATION . <br /> Name:Dougs mobile home service inc <br /> Address(including city, state, and ZIP):same <br /> Phone:same <br /> Email:same <br /> HOME INFORMATION <br /> Home ID number(ft-known): 1 DMV X-plate number(if known): <br /> Manufacturer:Clayton IMode1:72ins15523ab19 Year:2019 <br /> HUD label numbers: <br /> Serial numbers:38850 <br /> ADDRESS INFORMATION . <br /> Current location(including city, state,LIP):2445 Pacific Blvd Albany OR County:Linn <br /> Manufactured home park name, if applicable:Clayton Homes <br /> 0 Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot 1 Dealer name and contact information:Brian Fritterer <br /> Placement location (including city, state,ZIP):5355 River rd N Kiezer OR#35 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) $10 <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 /> VisaCard ❑Disco r Phone:(503) 799-0539 Department use only <br /> Carder signature Amount <br /> Doug Walton <br /> Name of cardholder as shown on credit card <br /> 4802137088004256 4 123 <br /> Credit card number Expiration <br /> CBS <br /> Consumer and <br /> Bushiss5ervices <br /> 440-5225(l0/L7/COM) <br />