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4 a.°1 A Y.e S b '1 --C1 aq S(-LIM\ <br /> wv:e <br /> � Manufactured Holrr a Trip Permit Application J 07 �, <br /> � c <br /> Department of Consumer and Business Services <br /> Building Codes Division <br /> 1535 Edgewater St.NW,Salem,;Oregon•Phone: 503-378-4530 •Fax: 503-378-41.01 <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 homeis 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 /> = '' ` ' AP:RUC:ANT INrFORMATIOail i` <br /> Nanie: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 /> _':TRANSPORTERINFORMATION, T , , <br /> Name:ROGERS HEAVY HAUL LLC <br /> Addiess(including city,state, and ZIP):12121 HILLCREST DR SE,YELM, WA 98587 <br /> Phone:360-507-7015 <br /> Email:YELMHAULING@GMAIL.COM <br /> ,,.; = HOMEIINFORMATION <br /> =Home ID number(if Inaown):NEW HOME DMV X-plate number(if known): <br /> Miinufacturer:MARLETTE Model:55CRC28643AH21 Year:2021 <br /> HUD label numbers:NTA2003081 /NTA2003082 <br /> Serial-numbers:HER032463OR A/B <br /> ADDRESS INFORMATION ' <br /> Ctirient:iodation(including city;state,ZIP):400 W ELM AVE, HERMISTON, OR 97838 County:Umatilla <br /> Manifactur'ed home parte name,ifapplicable: <br /> _0 Oregon dealer,lot Dealernatne:MARLETTE HOMES(Factory-new home) <br /> O'Out-of-state•dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):223242nd Ave:-SE,#929,Salem,.OR 9731.7 County:Marion <br /> Manufactured home park dame,if;applicable:Sundial Mobile Home Park . <br /> 0 Oregon dealer lot . Dealer name: <br /> \ <br /> Applioarit signature: ,.Tara Rivinius,Agent for Owner <br /> ���p1®'V. Amount , ;. <br /> Trip:permit-(per section) $5.00(70511-1195) $10.00 <br /> ,` . ;.?;. : TOTAL .. $10.00 <br /> Make.check or,money order payable:to.Department of Consumer and Business Services.If paying by credit card,_applicant <br /> mast sign credit card information box.Do not send cash.Secure fax: 503-947-2333 <br /> 0 Visa 0 MasterCard 0 Discover Phone:603) 363-6234Department use only <br /> $10.00 <br /> Cardholder signature Amount <br /> CPI SUNDIAL OWNER LLC <br /> Name of cardholder as shown on credit card <br /> l: <br /> Credit card number Expiration <br /> VVvDCBS <br /> ' ,Consuinerand <br /> 1' Business Services <br /> 44Q'5225;(10/l 7/COM)' <br /> Y; <br />