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our)c sLly Dr ME c;:), <br /> ABb <br /> at Lew) <br /> Manufactured Home Trip Permit Application <br /> iit,kr.1., D' Department of Consumer and Business Services <br /> O � <br /> vzi, Building Codes Division <br /> 1535 Edgewater St.NW, Salem,Oregon •Phone: 503-378-4530 •Fax: 503-378-4101 <br /> Web: oregon.gov/bed • 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 /> APPLICANT:INFO.RMATION .. .: ;< <br /> Name:Stephen P Crook <br /> Address(including city,state, and ZIP):2151 Three Lakes Rd. SE.#1 Albany, Oregon 97322 <br /> Phone:541-337-4197 <br /> Email:parksidemhcl@comcastnet <br /> TRANSPORTER INF.ORM'ATION <br /> Name:Bennett Truck Transport <br /> Address (including city,state, and ZIP):1360 Industrial Ave. Woodburn, Oregon 97071 , <br /> Phone:503-981-7939 <br /> Email:nancys.wbo@bennettig.com <br /> st,HOME INFORM'ATION:` .� ` ' <br /> Home ID number(if known): I DMV X-plate number(if known): <br /> Manufacturer:Fleetwood <br /> Model:Sandpointe 1 Year:2022 <br /> HUD label numbers:ORE 560023 <br /> Serial number s:FLE210OR22-22810A <br /> ADDRESS INFORMATION . <br /> Current location (including city, state, ZIP):1360 Industrial Ave.Woodburn, Oregon 97071 County:Marion_ <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot I Dealer name: <br /> ❑Out-of-state dealer lot I Dealer name and contact information: <br /> Placement location(including city, state,ZIP):4882 Lancaster Drive NE.#22 Salem, Oregon 97305 County:Marion <br /> Manufactured home park name, if applicable:Starlite MHC LLC <br /> 0 Oregon dealer lot FI—)ealer name: <br /> Applicant signature: <br /> Amount: ._ <br /> Trip permit(per section) $5 00(70511-1195) $ <br /> TOTAL' ' S <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 /> ❑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 /> BS <br /> tonsumtrand <br /> Business Services <br /> 440-5225(10/17/COM) <br />