Laserfiche WebLink
V Y13 3 a.oc <br /> ' '` Manufactured Home Trip Permit Application <br /> ktiVAS.:14 Department of Consumer and Business Services <br /> " Building Codes Division <br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530•Fax: 503-3784101 <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: ,�7.P/GZ /tel/I7&/�//6/eTLr .. <br /> Address(including city,state,and ZIP): <br /> Phone: jh/ GO '6-7,xS- <br /> Email: e z/LI/467Se CV/t/S,0 I Cori-4 - <br /> TRANSPORTER INFORMATION <br /> Name: 4,f O%T (O c.- vr7) <br /> Address(including city,state,and ZIP): p d •3 X 446 -4q 4 La Vol,6111i _1rt,yr-7a ,c 9 7 Li a7 <br /> Phone: 5-y/—y35-- 6 14. <br /> Email: F1/D T%?G q(o ?ft./AcG• <-6N- <br /> HOME INFORMATION <br /> Home ID number(if known): 13 64 JO DMV X-plate number(if known): <br /> Manufacturer: /I X672/Q U)P ModeI: G/,v�',uc '' Year:2 v 0( <br /> HUD label numbers: <br /> Serial numbers:* 1/8 27 913 <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP): /572a Acid frJf67'o'3 ag 4 73 SZ County:Ai:4/e <br /> Manufactured home park name,if applicable: <br /> El Oregon dealer Iot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP): S'2'S'S G/A 0%.5"/k4.c 0V v,P 577S/444 County: C/ivy <br /> Manufactured home park name,if applicable:,C/Q,e,,goir6 xfp6/4. - <br /> ❑Oregon dealer lot De ler name: <br /> Applicant signature: % J <br /> J Amount: <br /> Trip permit(per section) $5.00(70511-1195) $ f'j t� <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 /> 0 Visa El 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 /> @CBS <br /> ConsurnerBusinesSentles <br /> 440-5225(10/17/COM) <br />