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• <br /> , <br /> Manufactured Home Trip Permit Application <br /> ` �. "'-`, v Department of Consumer and Business Services <br /> ` > Building Codes Division <br /> crs 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530•Fax: 503-378-4101 <br /> Web: oregon.gov/bcd•Email: inhods.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 /> :•A P, TIO : •. .... ...._.. <br /> PP ICANT�INFORMATI N <br /> Name:Factdry Homes Clearance Center Inc <br /> Address(including city,state,and ZIP):18150 SW Boones Ferry Rd, Portland, OR 97224 <br /> Phone:971-224-2244 , <br /> Email:janetm@gunnerllc.com ' <br /> :... . . ... .. ..... TRANSPORTER INFORMATION '-':.::::: :.:: .::.':.:::::: ;::;:::.:.:;:::::::::;::::: .:;: <br /> Name:Doug's MH Setup&Service Inc <br /> Address(including city,state,and ZIP):12692 Fry Rd NE Aurora, OR 97002 <br /> Phone:503-799-0539 / <br /> Email:dugwalton@aol.com <br /> . . .. . . ... :.::.:HOME INFORMATION . : :. : ::: ::::::: :: <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Fleetwood Model:Weston Super Value c Year:2022 <br /> HUD label numbers:ORE 558219 <br /> Serial numbers:FLE2100R22-22303A <br /> .. .. .... DRESS INFORMATION ::.::.•::-': . ::'::: : ' '::` :` <br /> Current location(including city,state,ZIP):4735 Turner Rd SE Salem,OR 97317 : . .Connty:Marion . . <br /> Manufactured home park name,if applicable: . - • • <br /> El Oregon dealer lot Dealer name:Factory Homes Clearance Center Inc <br /> ❑Out-of-state dealer lot Dealer name and contact information: - <br /> Placement location(including city,state,ZIP):4783 38th Ave NE #13 Salem, OR 97305 County:Marion <br /> Manufactured home park name,if applicable:Apple Blossom MHP <br /> ❑Oregon dealer lot Deal •name: <br /> Applicant signature: �__.. ,ice'}- (ft ita T <br /> . ':::Amount: :': <br /> i 6 Trip permit(per section) $5.00(70511-1195) $5,00 , <br /> ......... .. ............:.. .............. ....... ... <br /> . i $5.00 <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 /> 0 Visa 0 MasterCard 0 Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> 1 <br /> Credit card number Expiration <br /> a CBS <br /> Businesssenlces <br /> 440-5225(t0/17/COM) ' <br />