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<br /> 4.-7,.. #,i.#, Manufactured Home Trip Permit Application
<br /> 'V"° ` • Department of Consumer and Business Services
<br /> ~,Z. Building Codes Division
<br /> 1535 Edgewater St.NW,Salem,Oregon®Phone: 503-378-4530•Fax: 503-378-4101
<br /> Web: oregon.gov/bcd o 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.
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<br /> Name:CPI SUNDIAL TRS LLC
<br /> Address(including city,state,and ZIP):4615 25TH AVE NE#701,SEATTLE,WA 98105
<br /> Phone:503-363-6234
<br /> Email:SUNDIAL@FCPNW.COM
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<br /> Name:ROGERS HEAVY HAUL LLC
<br /> Address(including city,state,and ZIP):12121 HILLCREST DR SE,YELM,WA 98587
<br /> Phone:360-507-7015
<br /> Email:YELMHAULING@GMAIL.COM .
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<br /> Home ID number Of known) I' EV/ DMV X-plate number(ifknown):
<br /> Manufacturer:MARLETTE Mode1:55CRC28563BH21 Year:2021
<br /> HUD label numbers:NTA1988869 I NTA1988870
<br /> Serial numbers:HER0325270RA/B
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<br /> • Current location(including city, state,Z.IP):400 W ELM AVE, HERMISTON, OR 97838 County:Umatilla
<br /> Manufactured home park name,if applicable:
<br /> El Oregon dealer lot Dealer name:MARLETTE HOMES (Factory-new home)
<br /> ❑Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city,state,ZIP):2232 42nd Ave SE,#590, Salem, OR 97317 County:Marion
<br /> Manufactured home park name,if applicable:Sundial Mobile Home Park
<br /> ❑Oregon dealer lot Dealer name:
<br /> Applicant signature: ,Tara Rivinius,Agent for Owner
<br /> Trip permit(per section) $5.00(70511-1195) $10.00
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<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 /> T ,_ - 17 - 'hone:5103) 363-6234 Department use only
<br /> .`�u_�_ $10.00
<br /> der signature Amount
<br /> CPI SUNDIAL OWNER LLC
<br /> Name of cardholder as shown on credit card
<br /> sign.Armaramorb
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<br /> Credit card number Expiration
<br /> i i 5� S
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<br /> ,. a Consumer and
<br /> Business Services
<br /> 440-5225(10/17/COM)
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