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_ <br /> �: r Manufactured Home Trip Permit Application <br /> > <br /> 41. - 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.gov/bcd •Email: nthods.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 /> submittedbe_fore the expiration date provided by the county at the time of certification. _... ._._ _ , _. ... _ <br /> ':.._'APP.LICANT°'INFORMATION <br /> Name:Factory Homes Clearance Cente Inc <br /> Addresi(nicluding city,-state,and ZIP):18150 SW Booties Ferry Rd Portland, OR 97224 <br /> Phone:971-224-2244 <br /> Email:'anetm -l @gunnertic.com , <br /> ' 'TRANSPORTER.INFORMATION <br /> Name:Phil Sterline <br /> Address(including city,state,and ZIP):17230 Beck Rd Dallas, OR 97338 -~ - <br /> Phone:503-932-2629 . . _ -. <br /> Email:philsterling1@gmail.com <br /> .. .'•.' HOME INFORMATION . :`.:,:: • <br /> . •::; <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Fleetwood Model:Sandpointe Year:2023 <br /> HUD label numbers:ORE 560808 <br /> Serial-Mithbe s:FLE210OR23-23077A <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 /> n Oregon dealer lot - Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):2200 Lancaster Dr SE 1110A Salem OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: <br /> .'Amount:::':. <br /> . ... ..... .... <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> :: :;:TaTAL :` $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:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> / .i <br /> Credit card number Expiration <br /> a . <br /> .!DCBS <br /> 'l (oesumesand <br /> Business Services <br /> 440-5225(10/17/COM) <br />