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aaoo i_aflcc.5 -eV Or E 1 �4_ Sal <br /> •eve <br /> 7".;}�, Manufactured Home Trip Permit Application <br /> „... Department of Consumer and Business Services <br /> r" Building Codes Division <br /> 1535 Edgewater St,NW, Salem, Oregon•Phone: 503-378-4530 •Fax: 503-378-4101 <br /> Web: oregon.gov/bed•Email: inhods.bcd a 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 /> :: :::�APPL'ICANT.::INFORMATION <br /> Name:Factory 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@gunnerilc.com 11-cr7 j 0 (0 5O3 <br /> ... . .. ... . : ... : TRANSPORTER INFORMATION`• <br /> Name:Newman's Transport <br /> Address(including city, state,andZIP):P 0 Box 236 Sllverton, OR 97381 <br /> Phone:503-932-5142 <br /> Email:Jlnwnn@gmail.com <br /> ;`' HOM E INFORMATION':: :.'`:. ';;; '::::::: .::.:;;;;• ;.:.,. : ;: : :::.:::: : :: :;; <br /> Home ID number(if known): 'NI E V. DMV X-plate number(if known): <br /> Manufacturer:Skyline Model:West Ridge Year:2022 <br /> HUD label numbers:ORE 558524 ORE558525 <br /> Serial numbers:245-000-H-A101214AB <br /> :: :..... .....:... :ADDRESS INFORMATION.,' :.:; :. :.::.: :.... .... <br /> ; ::::: <br /> Current location(including city, state,ZIP):4735 Turner Rd SE Salem, OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> O Oregon dealer lot Dealer name: <br /> 0 Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):2200 Lancaster Dr SE ii6A Salem, OR 97317 County:Marion , <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer 1 eater name: <br /> Applicant signatur : �,,4i/ ) , <br /> ..::.-::,--Ani <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 /> must sign credit card information box,Do not send cash,Secure fax: 503-947-2333 <br /> 0 Visa 0 MasterCard ❑Discover Phone:( ) <br /> Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> `liDCBS <br /> 1 (onwmerand <br /> tu,fnessSeiWi s <br /> 440-5225(10/17/CUM) <br />