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'�f'' ''t�, Manufactured 1Xome 'Trig) Permit Application .Co 0(9 5 )-�
<br /> • 4:::_,.7,,,,.„13, 1 Department of Consumer aid Busiuess.Services
<br /> �.- Building Codes Division
<br /> 1535 Edgewater St, NW, Salem,Oregon 'Phone: 503-378-4530 • Fax: 503-378-4101
<br /> Web: oregon,gov/bcd •Email: iithods,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 /> :.: .. :: AP:..PLICANT INF:ORMAT.ION:.. .
<br /> , Name:Factory.Homes Clearance Center Inc
<br /> Address(including city,state, and ZIP):18150 SW Scones Ferry Rd Portland, OR 97224
<br /> Phone:971-224-2244
<br /> Emall:Janetm@gunnerlic,com
<br /> . . . ... TRANSPORTER INFORMATION •,. .; :: .: :.: ~. :.:., ..
<br /> Name:Doug's MH Transport and Setup Inc
<br /> Address(including city,state, and ZIP):12692 Fry Rd NE Aurora OR 97002
<br /> Phone:503-799-0539
<br /> .Email:dugwaiton@a01,com
<br /> ...: HOME INFORMATION : .. -. . .,. , ::: ::
<br /> Home 1D number(f know): DMV X-plate number(if known):
<br /> Manufacturer:Fleetwood . Model:Waverly Crest Year:2023
<br /> HUD label numbers:ORE 569646 ORE 569546
<br /> Serial iumibers:FLE210OR22-22696A FLE3200R22-22696E
<br /> . • . . . .... ... . ... ......... .. •.•..::ADDRESS INFORMATION . ::.. : . :.. :::.: ::::: .
<br /> Current location(including city, state,ZIP):2917 N Pacific hwy Woodburn, OR 97071 County:Marlon _
<br /> Manufactured.home park name, if applicable:Storage
<br /> ❑Oregon dealer lot Dealer name:
<br /> ❑Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city,state,ZIP):3100 Turner Rd SE#422 Salem, OR 97302 County:Marlon ,
<br /> Manufactured home park name, if applicable:Paradise Island
<br /> ❑Oregon dealer lot Dealer n ie:
<br /> Applicant.signature: ,41,y,,,1r 1( A/ S. )
<br /> •
<br /> •,"•,• . .„.. • ....,..„
<br /> Amount:
<br /> ../ Trip permit(per section) $5.00(70511-1.195) $10.00
<br /> ..... ...... . ......... ... . ....... ............... ... .... '"".TOTAL'':'::: $10,00
<br /> Make checic 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 ❑Discover Phone:( ) Department use only
<br /> Cardholder signature • Amount •
<br /> Name of cardholder as shown on credit card ,
<br /> . Credit card number Expiration
<br /> iDCBS
<br /> lI Consumland
<br /> Budness Stakes •
<br /> 440-5225(10/17/COM)
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