Laserfiche WebLink
t <br /> P ' '4155 Lcca6y Cr • of 46 6 a k <br /> , .,.��* Manufactured Home Trip Permit Application <br /> ro*iiii <br /> Department of Consumer and Business Services <br /> • <br /> `�j 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 hone 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:CHEMEKETA MV <br /> Address(including city, state,and ZIP):4155 LANCASTER DR NE SALEM, OR 97305 <br /> Phone:503.362.1281 <br /> Email:CHEMEKETAMV@GMAIL.COM <br /> - '<:. TRANSPORTER INFORMATION . <br /> Name:SITE INSPECTION SERVICES, LLC <br /> Address(including city, state,and ZIP):2390 ALMEDA ST NE SALEM, OR 97301 <br /> Phone:503.3759440 <br /> Email: <br /> ., HOME INFORMATION' , <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:GLEN RIVER Model: Year:1985 <br /> HUD label numbers: <br /> Serial numbers:GR2340X20 <br /> ADDRESS INFORMATION <br /> Current location (including city, state, ZIP):32606 44TH AVE NW STANWOOD,WA 98292 County: <br /> Manufactured home park name, if applicable: <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):4155 LANCASTER DR NE UNIT 8B County:MARION <br /> Manufactured home park name, if applicable:CHEMEKETA MV <br /> ❑Oregon dealer lot De:ler name:_/ <br /> Applicant signature: `= '6' <br /> . Amount:.' <br /> Trip permit(per section) 55.00(70511-1195) S .?r— <br /> . ' - .. TOTAL ,'> $ 5.--- <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 /> El Visa El MasterCard El Discover Phone:(je3)i5t-(—1-70C Department use only <br /> , <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card nuiiiber Expiration <br /> ®CBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/I7/COM) <br />