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Manufactured Home Trip Permit Application <br /> Otok <br /> \,-1) Department of Consumer and Business Services <br /> Building Codes Division <br /> 1535 Edgewater St.NW,Salem,Oregon•Phone: 503-378-4530 •Fax: 503-378-4101 <br /> Web: oregon.govibcd •Email: mlvds.bcd@oregon.gov <br /> This application must be submitted with a valid tax certification from the county in which the home is currently IOCated, ; <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 /> Name:Factory Homes Clearance Cente Inc <br /> Address(including city,state,and ZIP):18150 SW Boones Ferry Rd Portland, OR 97224 <br /> Phone:971-224-2244 - <br /> Emaillanetm@gunnerlIc.com <br /> : .1 TRANSPORTER INFORMATION <br /> Namd:PhIl Sterline <br /> Address(including city,state,and ZIP):17230 Beck Rd Dallas, OR 97338 <br /> Phone:503-932-2629 <br /> Emailiphilsterling1@gmail.com <br /> ••• ' • HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Fleetwood Model:Sandpointe Year:2023 <br /> I-I4D label inimbers:ORE 560829 .„. <br /> Seri4iinnibers:FLE2100R23-23097A <br /> • • , '''::•:ADDRESS INFORMATION <br /> Current location(including city,state,ZIP):2655 Progress Way Woodburn OR 97071 County:Marion <br /> Manufactured home park name,if applicable: <br /> CI Oregon dealer lot Dealer name: <br /> Out-of-state dealer tot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):2200 Lancaster Dr SE #11A Salem OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> Oregon dealer lot Dealer name: <br /> :Applicant signature: <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> $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 /> D 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 /> . . <br /> fit-D]CBS <br /> i=g <br /> Burr, <br /> , <br /> 440-5225(I 0/17/COlvi) • <br /> • <br />