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1 <br /> i+f,' `r. Manufactured Home Trip Permit Application <br /> ' �"ro. De Department of Consumer and Business Services <br /> Frl.. I] <br /> 4`�or Building Codes Division <br /> t% <br /> 1535 Edgewater St,NW, Salem,Oregon •Phone: 503-378-4530 •Fax: 503-378-4101 <br /> Web: oregon.gov/bcd•Email: mhods.bcd a oregon,gov <br /> • This application iuust 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 /> :: :APPLIaANIINFORMATI.ON: <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 <br /> ... , . . ... .: .: . :. : . TRANSPORTER INFORMATION :: `:: <br /> Natite:Phil Sterling <br /> Address(including city,state,and ZIP):17230 Beck Rd Dallas, OR 97338 <br /> Phone:503.932-2629 <br /> Email:philsteriing1 @gmall.com <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if]mown): <br /> Manufacturer:Fleetwood Model:Sandpointe Year:2023 <br /> HUD label numbers;ORE 560814 <br /> Serial numbers:FLE210OR23-23082A <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP):2655 Progress Way Woodburnd, OR 97071 County:Marion , <br /> Manufactured home pack name,if applicable: <br /> p Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer tot Dealer name and contact information: <br /> Placement location(including city,state,Z1P):2200 Lancaster Dr SE 5C Salem OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: ri0/114‘ I y Vy <br /> J .-.'.-.-:-Amount':.:' '.• <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> TOTAL: ::: $5.00 <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 /> ❑Visa ❑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 /> u= <br /> i CBS <br /> -= Consumer and <br /> (Witness Services <br /> 440-5225(10/17/COM) <br />