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is <br /> �`.. e. <br /> ti._b Manufactured Home Trip Permit Application <br /> �j Department of Consumer and Business Services <br /> t ' Building Codes Division <br /> � � 1535 Edgewater St,NW,Salem Oregon•Phone: 503-378-4530 •Fax: 503-378-4101 • <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 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 /> :PL 'GAN TAN FOIRMATIO . .... <br /> Name:Factory Homes Clearance Center Inc _ <br /> Address(including city,state,and Z113):18150 SW'13oones Ferry Rd Portland, OR 972.24 ' <br /> Phone:971-224-2244 <br /> Email:Janetm@gunnerllc,com • <br /> F . . . <br /> '..:•..':'''::: :;:•..::.2..::..-...TRANSPORTER INFORMATION .�. ;:�.: . <br /> :.: :.:::; :; •.:��``' :::::` • :.::.`: <br /> Name:Doug's MH Setup&Service <br /> Address(including city, state,and ZIP):12692 Frey Rd NE Aurora, OR 97002 <br /> Phone:971-224-2244 <br /> Email:)anetm@gunnerllc,com <br /> :;;+ t ;:•::::.::, •: HOME INFORMATION ;'. .. :': ::: : <br /> • Home ID number(if known):183088 DMV X-plate number(if known): <br /> Manufacturer:FREEd Model:Unknown Year:1974 <br /> HUD label numbers:NA <br /> Serial numbers:52242CK0891980H 52242CK0891980H <br /> :*:: ::-.:::;.:::;1 .,:.:,.:::::::',:;::: .. . ... ..ADDRESS INFORMATION .: <br /> —_ <br /> Current location(including city,state,ZIP):4725 Turner Rd SE SAlem, OR 97317 County:Marlon <br /> Manufactured home park name,if applicable: <br /> O Oregon dealer lot Dealer name: l_ <br /> 0 Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP 1530 Tamarack St '#12 Sweet 1-lome OR 97386 County:Linn <br /> Manufactured home park name,if applicable:Tamarack Ridge <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: <br /> ,.Atnoiint <br /> Trip permit(per section) $5.00(70511-1195) $10,0010.00 <br /> Make check or money order payable to Department of Consumer and Business Services,If paying by credit card,applicant <br /> mist sign credit card information box.Do not scud cash.Secure fax: 503-947-2333 <br /> 0 Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> r <br /> Credit card number Expiration <br /> !DCBS <br /> (onsumerand <br /> sudnessSodas <br /> ‘10-5225(10/17/COM) <br />