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• <br /> 41:1,Z-% Manufactured Home Trip Permit Application <br /> Department of Consumer and Business Services <br /> -17 Building Codes Division <br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530 •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: PATRICIA CUNNINGHAM; JOHN PINARD <br /> Address(including city, state, and ZIP):245 N SANTIAM HWY E., #19, GATES, OR 97345 <br /> Phone:503-551-1165 <br /> Email:OREGONLADY54@GMAIL.COM <br /> TRANSPORTER INFORMATION <br /> Name:MARTIN DUNN-SITE INSPECTION SERVICE, LLC <br /> Address (including city, state,and ZIP):2390 ALAMEDA ST. NE, SALEM, OR 97301 <br /> Phone:503-991-1808 <br /> Email: <br /> HOME INFORMATION <br /> Home ID number(if known): 198626 DMV X-plate number(if known): X00125349 <br /> Manufacturer: SKYLINE Model: HILLCREST Year: 1975 <br /> HUD label numbers: <br /> Serial numbers: 02950403J <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP): 2232 42ND AVE SE,#588, SALEM, OR 97317 County: MARION <br /> Manufactured home park name, if applicable: SUNDIAL MOBILE HOME PARK <br /> El Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):245 N SANTIAM HWY E., #19, GATES, OR 97346 County:MARION <br /> Manufactured home par. n e, 'f applicable:DEER CREEK LLOW SENIOR MOBILE HOME PARK <br /> ['Oregon dealer lot D-aleeato; <br /> Applicant signature: ; 17/ � c��`� <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> TOTAL $5.00 <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 ❑Discover Phone:( ) Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> BS <br /> Consumer and <br /> Business Stwkes <br /> 440-5225(10/17/COM) <br />