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<br /> Manufactured Home Trip Permit Application . .
<br /> cc.zy •Department of Consumer and Business Services
<br /> . 1 Building Codes Division
<br /> 1535 Edgewater St. NW, Salem, Oregon•Phone: 503-378-4530 • Fax: 503-378-4101 1 I .. .-
<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 /> 161111414"3111111"11106140010MMIVRMVONMISIIIIIIMIUMM,la'.
<br /> Name SUPERIOR HOME TRANSPORT, LLC
<br /> -- Address(including city,:state,and ZIP):PO BOX 1067, JEFFERSON, OR 97352
<br /> '..,Phdorie:541-327-7805 , ... .. _
<br /> Ernail;RITAFiARTZELL@GMAIL.COM
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<br /> AgicS UPER I OR HOME TRANSPORT, LLC
<br /> Address(including city,state,and ZIP):PO BOX 1067, JEFFERSON, OR 97352
<br /> 17111one:541-327-7805
<br /> Email:RITAHARTZELL@GMAIL.COM
<br /> Vagair ttomo'N#0,AMATION,,AnanithigatgagOOMAY
<br /> Home ID number(if known):181818 DMV X-plate number(if known):
<br /> Manufacturer:CHAMPION Model:TITAN Year:1974
<br /> HUD label numbers:.
<br /> Seiial ininibers:40457400892
<br /> 14:1Virl'444‘411). -0"k"I''''''X'ADIAESSINFORIVIATIOtt,'Nv
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<br /> !Current location(including city,state,ZIP):4915 SWEGLE DR NE, SPC 17 County:MARION
<br /> Manufactured home p ark name,if applicable:SUNSET VILLAGE
<br /> a I
<br /> Oregon dealer JotDealer name:
<br /> D Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city,state,ZIP):950 AIRPORT RD, SPC 85, ALBANY, OR 97322 County:LINN
<br /> Manufactured home park name,if applicable:SEQUOIA ESTATES
<br /> El Oregon dealer lot Dear name:
<br /> Applicant signature: ,,;(6---=-',...___.
<br /> Trip permit(per section) $5:00(705I1-119,5), $
<br /> - On Ari'IMMORISMOSMANAMMTAS $
<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 /> Credit card number Expiration
<br /> 10 r%r
<br /> 41 /2 DJ
<br /> •
<br /> DAMS Settte%
<br /> 440-5225(I 0/17/COM)
<br />
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