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<br /> Manufactured Home Trip Permit Application ,3&Uta�
<br /> V,,.:1:-'7.1rDepartment of Consumer and Business Services
<br /> Building Codes Division
<br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530•Fax: 503-378-4101
<br /> Web: oregon.govibcd•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:Factory Expo Homes
<br /> Address(including city,state,and ZIP):2555 Progress Way,Woodburn, OR. 97071
<br /> Phone:503-981-0770
<br /> Email:moconnell@factoryexpohomes.com
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<br /> Name: Superior Home Transport, LLC
<br /> Address (including city,state,and ZIP): PO Box 1067 Jefferson, OR. 97352
<br /> Phone: 541-327-7807
<br /> Email: ritahartzell(c�gmail.com
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<br /> Home ID number(if known): DMV X-plate number(if known):
<br /> Manufacturer:Fleetwood Model: Redding 28483T Year: 2021
<br /> HUD label numbers:
<br /> Serial numbers: FLE2100R21-21431 AB
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<br /> Current location(including city,state,ZIP):2555 Progress Way,Woodburn, OR. 97071 County:Marion
<br /> Manufactured home park name,if applicable:
<br /> ❑■ Oregon dealer lot Dealer name:Factory Expo Homes
<br /> 0 Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city,state,ZIP): 5220 Ramp St. NE, Salem OR. 97305 County: Marion
<br /> Manufactured home park name,if applicable:
<br /> ❑Oregon dealer lot Dealer name:
<br /> Applicant signature: 2e. ((drf.-4-
<br /> Trip permit(per section) $5.00 S70511-1195) $
<br /> rglii MA`"`,._Y-�',s�;s"��t t{xaga_: fm' Izwo $
<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 0 Discover Phone:( ) Department use only
<br /> $
<br /> Cardholder signature Amount
<br /> Name of cardholder as shown on credit card
<br /> Credit card number Expiration
<br /> FA
<br /> WI Di BS
<br /> ;11
<br /> „1,: Consumer and
<br /> Business Smits
<br /> 440-5225(10/17/COM)
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