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• y Manufactured Home Trip Permit Application
<br /> : /di Department of Consumer and Business Services
<br /> ,. s, Building Codes Division
<br /> 1535 Edgewater St.NW, Salem, Oregon®Phone: 503-378-4530 • Fax: 503-378-4101 •
<br /> - Web: oregon.gov/bcd Email: mhods.bcd(c4ore on.g ov
<br /> This application must be submitted with a valid tax certification from the county in which the home is currently located,,
<br /> as'we11 as the county the home is moving to. A valid tax certification is one that has been certified by the county and
<br /> `subm.iited before the expiration date provided by the county at the time of certification. i!r l a 5 (0-7c,,
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<br /> :Name:SUPERIOR HOME TRANSPORT, LLC
<br /> Address (including city, state, and ZIP):PO BOX 1067,JEFFERSON, OR 97352
<br /> Phone:541-327-7805
<br /> Email RITAHARTZELL@GMAIL COMt �j {tit/��g #� k x"
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<br /> Natme:SUPERIQR HOME TRANSPORT, LLC
<br /> Address (including city,state, and ZIP):PO BOX 1067, JEFFERSON, OR 97352
<br /> Phone:541-327-7805
<br /> Email RITAHARTZELL@GMAIL COM
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<br /> Ilome ID number(if known):181818 DIM X-plate number(if known):
<br /> Manufacturer:CHAMPION Model:TITAN Year:1974
<br /> HUD label numbers:
<br /> Serial numbers 404574D0892
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<br /> Current location(including city,state,Z1P):4915 SWEGLE DR NE, SPC 17 County:MARION
<br /> Manufactured home park name, if applicable:SUNSET VILLAGE
<br /> 0 Oregon dealer lot Dealer name:
<br /> 0 Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(includin_ city, state;ZIP):950 AIRPORT RD, SPC 85, ALBANY, OR 97322 County:LINN
<br /> Manufactured home park name,if applicable:SEQUOIA ESTATES
<br /> 0 Oregon dealer lot Deal1r name:
<br /> Applicant signature: % -
<br /> Trip permit(per section), $5.00�70511 1195) S
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<br /> Make check or money order payable to Department of Consumer and Business Services. If paying by credit card,applicant
<br /> must si n 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 /> Cardholder signature Amount
<br /> Name of cardholder as shown on credit card
<br /> Credit card number Expiration
<br /> Okat s
<br /> Conss Ser:/xnv and
<br /> 440-5225(10117ICOM)
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