|
se-11-5s (00 0 4 b l
<br /> Manufactured Home Trip Permit Application
<br /> t Department of Consumer and Business Services
<br /> `° Building Codes Division
<br /> 1535 Edgewater St.NW, Salem,Oregon Phone: 503-378.45300 Fax: 503-378-4101
<br /> Web: oregon.gov/bcd o Email: mhods.bed@,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 /> 1 :.L .,.t .l.i „0 :.�;..ai 'rr .'t•rt.l', ,:^r�yr,5�:;rfay.?:"" ::i:, £
<br /> $,. `nwi-ti`�:t, 8J. i��, ito-.;= .�.. •r :a_ .%r}:F.vs�-:i,::`r'.. >u.
<br /> i.
<br /> .�1.'r '{... 4. ✓f• :�-_� .,�r:,rr. �:Fl:it?2:,.rp.",1 ,.l•
<br /> h�..:."q1-^-1n' ) S'�� i� f i if lat%i�•' c.[t, ..(•
<br /> - ..-Fa..
<br /> ^'X?:
<br /> .r 1 - -
<br /> .....,,.d.,.. .t.r..,?...>...-r..._, 1..^... ..,. r_.:�m_ ,:.n.w.. .{ h•r.. ..........., ei ...4 s. ,.l,.r.:c• .:.. ,. .�� ._�... ,?...,....:>.%..•s`+,'^"_•{:i...,......,u:,.<x ... ....s, n:1.zL:d?..^ ....1=:%r::8-id!:'r.>�;Si':.
<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
<br /> NSRO.RTE I FO A. IO
<br /> '41. •}
<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:YE LMHAU LI NG@G MAI L.COM
<br /> OM � R TI °•
<br /> Home ID number(if known): g j E DMV X-plate number Of known):
<br /> Manufacturer:MARLETTE Model:55MJC24523AH21 Year:2021
<br /> HUD label numbers:NTA1988863/NTA1988864
<br /> Serial numbers:HER032503OR NB
<br /> .. ...........:.:....:• ....... ,:r:.:...:. . DD . ESS: F.aRM .TI
<br /> Current location(including city,state,ZIP):400 W ELM AVE, HERMISTON, OR 97838 County:Umatilla
<br /> Manufactured home park name,if applicable:
<br /> ®Oregon dealer lot Dealer name:MARLETTE HOMES(Factory-new home)
<br /> O Out-of-state dealer lot Dealer name and contact information:
<br /> Placement 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 /> ❑Oregon dealer lot Dealer name:
<br /> Applicant signature: , , , Tara Rivinius,Agent for Owner
<br /> NTIO
<br /> Trip permit(per section) $5.00 470511-1195) $10.00
<br /> - r):::E�. �:tY,v>:^:>: :7if^:a._ six::, -
<br /> '.^f ii!�! .}ti '•:? -tot. .>-�i: '.:1.
<br /> ..�,_^ �iE;. :>;:< - r;7.'� AL;, $10.00
<br /> :s:
<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 /> _ w+ — _ Phone:(503) 363-6234 Department use only
<br /> ` t $10.00
<br /> ,+�:'' a r older signature Amount
<br /> CPI SUNDIAL OWNER LLC
<br /> Name of cardholder as shown on credit card
<br /> Credit card number Expiration
<br /> t ;i CS
<br /> Consumer and
<br /> Minos Services
<br /> 440-5225(10/17/COM)
<br />
|