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<br /> ,�° N Manufactured Home Tri Permit A licatio
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<br /> ti Pr'.' 11 DeDepartment of Consumer and Business Services
<br /> „isBuilding Codes Division T RC -11 9e- AO ne>
<br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530 •Fax: 5 3-378-4101
<br /> Web: oregon.gov/bcd• Email: mhods.bcd@oregon.gov •
<br /> MOV to Nanon cc .
<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 th.county and
<br /> submitted before the expiration date provided by the county at the time of certification. y2 ; : - t rs IS
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<br /> Name: °`
<br /> Address(including city, state, and�ZIP): f :i 0 6 a • t t u 4' , . '
<br /> Phone: �'�4 (,, i - 6Ib g i •
<br /> Email: 'hr7.a.-M`ile ti ct' re- p {{
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<br /> -�� � .. ..1. •" .:. � -tet:. r-`�,x�,'-Y,'=,r£•<•:'^`F>t::.
<br /> Name: On 4N �
<br /> Address (including city, stated ZIP): 1 ��
<br /> Phone: $0 3 - 750 - 9 71(4 scbc3 — Z c 1 - ggec o
<br /> Email:
<br /> • . ... •:.:; l ,i;z.. .k1.•''1i7ery'_' M;COItttfNFYRNAtIOlt' ';. ::.=�.:.-:r.+..[•:. `„;.4 : �': 7�y :P
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<br /> Home ID number(if known): 3 3 7,57$ I
<br /> DMV X-plate number(if known):
<br /> Manufacturer: (b`&4:2 z+ • - I Model: I Year: ab(Cf
<br /> HUD label numbers: o Y-,_ S 1, 1--':,,2 Q i•,Q 9 l $''3
<br /> Serial numbers: P
<br /> .... .. o3y � � 9 cam.
<br /> . .. .... . .:... A:; ' I�' i4DReSOF4ZMANN{ 1 0hI aF -
<br /> ( T
<br /> Current location (including city, state,ZIP): /f0 oS—J 00cfC ij 3(� � County: Obi Cz4
<br /> 44.5
<br /> Manufactured home park name, if applicable: • Q r ,� �vlyq7ocp-
<br /> ❑Oregon dealer lot Dealer name:
<br /> ❑ Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city, state, ZIP): f 5q, O y JO LO,t/A-•t^a•Yv`. 5 f^ County:Jgl,r;�
<br /> Manufactured home park name, if applicable: _ 4-p,r` d 5-R
<br /> ❑Oregon dealer lot D, 62er name: _
<br /> Applicant signature: /4.4A. P'1 • , I/ Air( w
<br /> ,,,e41424e—,7 ,/‘1
<br /> Trip permit(per section) $5 00 (70511-1195) $ /D . 00
<br /> tib•' *.r' •L�? 'r^`s ,a3'i*4r tf-r �'.F 4�. -. TA 2 0
<br /> ^.�tt•..; +•ai:•3: t,i..� :..F't.��,?'.-a�•�ri.'k,?i.., �r•.r.Y,:=!:�S,Gfl 1L„u•7! $i 0 v
<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 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 /> .
<br /> DCB
<br /> ConsumerandS
<br /> Business Services
<br /> 440-5225(10/17/COM)
<br />
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