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I '3, <br /> ,C0O(Jo.44 <br /> Manufactured 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: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:503.375.9440 <br /> Email: <br /> ;HOME INFORMATION <br /> Home ID number(if/nnotivn):395124 DMV X-plate number(if/mown): <br /> Manufacturer:FLEETWOOD Model:NA Year:1976 <br /> HUD label numbers: <br /> Serial numbers:24X64S2482 A/B <br /> . :ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):37946 Mountain Home Dr Brownsville, OR 97327 County:Linn <br /> Manufactured home park.iiame, if applicable: <br /> ❑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 8A County:MARION <br /> Manufactured home parlc'name, if applicable:CHEMEKETA MV <br /> D Oregon dealer lot Dealer name: <br /> Applicant signature: G %auk <br /> Cl Arnount._ <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 /> _l�' $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card nu[nber Expiration <br /> °DCBS t <br /> Consume/and <br /> Business Services <br /> 440-5225(10/17/COM) <br />