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<br /> 0005377
<br /> ,-'-- . 4•04,.: Mannfactured Horne Trip Permit Application
<br />''. '' , ', 43,st • .-._ - _ . - .
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<br /> 'Department of Consumer and Business Services I•: :,
<br /> ' Building Codes Division '',•;:f,:.,:•
<br /> . . 1535 Edgewater.St.NW, Salem,Oregon•Phone: 503-378-4530 • Fax: 503-378-4101
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<br /> Web:oregon,goylbod •Email: rnhods.bed@pregon.gov
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<br /> This application must be submitted with a valid tax certification from the county in which the home is currently located,
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<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 . ,.:.
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<br /> submitted before the expiration date provided by the county at the time of certificatioh.
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<br /> ., . 14ain :CPI SUNDIAL TRS LLC ..: .;.
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<br /> Address(including city,state,and:ZIP)4615 25TH AVE NE#701, SEATTLE,WA 98105
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<br /> Pbohe:503-363,624 , ....
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<br /> ...' .'.1- '1:-5;•.Oniggat':::::.'iAig1=•''W'-'''' '-'''..;4:::',. ''s - ..17FRAN$R01.13,17e'.R.ARFORA'iY.A:VioiN:i'_-;,.::..:tiz,-.:;.::;'ir,a1*';:;:-',
<br /> .., : Nnitie:ROQERS HEAVY HAUL LLQ . ..
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<br /> Address(including City,-State,and ZIP) 12121 HILLCREST DR SE,YELM,.WA 98587. •
<br /> 2 ,' Phone:360-507-7015 •-..:,
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<br /> Email:YELMHAOLINQ@GMAIL.COM
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<br /> golii.oID number orkhowio;,N106 HOME DMV)(74A00 number(if/mown)
<br /> ...,. Marinfacthrer!MARLETTE ModeL5.5CRO28643AH21 Year:2021
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<br /> HUI)label:nun:lbw's:NTA1988890/NTA1988889
<br /> Serial numbers:HER032598OR A/8
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<br /> Current location(including city,state,ZIP):400.W ELM AVE, HERMISTON, OR 97838 Cottrity:Pmatilla
<br /> Manufactured hOthe park name, if applicable:.
<br /> Oregon dealer lot Dealer name:MARLETTE HOMES (Factory.-new home)
<br /> DI Out-of-state dealer lot Dealer name and contact information:
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<br /> Placement location(including city;state,ZIP) 2, 32 42nd Ave,i:SE;-#796;8alern,:-OR.,97317 COmitY:Marion• •1:••,
<br /> Manufactured home park name, iflapplicable:Sundial MObile.Horne Park
<br /> •0 OregOn dealer lot Dealer name: • • .,
<br /> .Applicant signature: Nik . '• - ,Tara RivieiuS, Agent for Owner • ..
<br /> Aiek ...v V'`7%.•
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<br /> Trip permit(per section) $5.00(70511-119 ) $10.00
<br /> .',`:,11-;;?.-:2::-.':.q.Z..,. . C.:'„a:V.1,-!.... 7:' ,:- ••,,:', ';',.':::' ,11.01,-4-;',!.4 $10.00
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<br /> Make check or money-order payable to Department of Consumer and Buine:ss'Sel..Vices.If paying by credit ON,applicant
<br /> must sign titdittiiIII inforniatIOO box.Do not soil cash Secure fax 503-947-2333
<br /> 0 Visa 0 Mastofcrq 0 DiscoVer 13.).rorre: 03)363-624 . . . '
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<br /> Department use only
<br /> Cardholder signature Amount . •
<br /> ' . . . CPI SUNDIAL OWNER LLC
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<br /> Name Of cardholder as shown on credit card
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<br /> Credit card number Expiration
<br /> '' :.• - ODCBS •
<br /> ,' Consuineiand'
<br /> • ' - Busi9Css Services. • . • ...,
<br /> 440-$225:,(10117/boN1).
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