Laserfiche WebLink
‘4Manufactured Home Trip Permit Application <br /> `-"-' ' • Department of Consumer and Business Services <br /> :r" 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: A,4y‘v/e 44i L <br /> Address(including city,state,and 34 ZIP): ' t 7 0 seh/ayt /et ,4'.t/,p., C,2 <br /> Phone: $ /- y/f y 8a 9 770/ <br /> Email: II ti lev e Aoreno G. con--) <br /> ' TRANSPORTER INFORMATIONName: /9ney'/per /f74Qi iG AMC�lo /"2/s//Na ! C0,7d'Gs.71i011/1 LLC. <br /> Address (including city,state, and ZIP):a,59/o eti,. r/NS 1i9,ve f 149i✓gTAi of f2 f/ef? <br /> Phone: ,may/- J$9: $f7 � <br /> Email: /90r,ON 7 3d//iv.vy ,C1,r)A1 L• Cd.•l <br /> i HOME INFORMATION <br /> Home ID number(if known): J95/e77 DMV X-plate number(i known): <br /> Manufacturer:CA/1h/ /12m/afNGremi,�/ /e. 7 ,r,..,d. Model: 7���/l/1.38YS/4flRyj$ear: o?#/o <br /> HUD label numbers: ev E 33 3.3/ e9'et .5-333/7 <br /> Serial numbers: I '94 036,5876-/2A 4 y-Le '3 $ 'Z6 <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):/917 sr elwig 1'E ICdf/O/ 1ff14400/,aft Count 0/1.4, / <br /> Manufactured home park name,if applicable: /(//q f'7.5,fa <br /> ❑Oregon dealer lot Dealer name: Al//9 <br /> O Out-of-state dealer lot :Dealer name and contact information: iv/i9 <br /> Placement location(including city,state,ZIP):/�.le /9c J/r/o 7W .T '613Y y County: e.dc <br /> Manufactured home park name, if applicable: il/f Zft 6LEA/ (woe r, ,,,7avp e, '& O • <br /> ❑Oregon dealer lot Dealer name: v <br /> Applicant signature: <br /> Amount: <br /> Trip permit(per sectio �) $5.00(70511-1195) $ <br /> TOTAL $/ .ec <br /> Make check or money orderpayable 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 /> Vi 0 MasterCa 0 D':cover Phone:(1/465//- V/9-yO SA <br /> Department use only <br /> $ /D. 06 <br /> Cardholder a fe Amount <br /> /2//AA& ,:%_tk4 <br /> Name of cardholder as shown on redit card <br /> g/5/7 a 99.x- a$s9 85/VY a3 i a3 <br /> Credit card number Expiration <br /> ifiDCBS <br /> Consumer and +, <br /> Business Services <br /> 440-5225(10/17/COM) -, <br />