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N., Manufactured Home Trip Permit Application _ <br /> y' , Department of Consumer and Business Services <br /> ,L, <br /> ilio. Building Codes Division .rIta <br /> . <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 /> submitted before the expiration date provided by the county at the time of certification. <br /> •.:'APPLICANT-INFORMATION i <br /> Name:Factory Homes Clearance Conte Inc - <br /> Address(including city,state,and ZIP):18150 SW Boones Ferry Rd Portland, OR 97224 <br /> Phone:971-224-2244 <br /> Email:janetm@gunnerllc.com 1 -- <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@gmall.com <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): - <br /> Manufacturer:Fleetwood Model:Sandpointe Year:2023 <br /> HUD label nttmbers:ORE 560808 <br /> Serial:itumbe s;FLE21OOR23-23077A <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 /> p 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 #10A Salem OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: <br /> ' :Amount <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> _. `:TOTAL ... $5.00 <br /> Make checkor 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 /> El Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> / - <br /> Credit card*number Expiration <br /> titDCBs <br /> (onwmer and <br /> Minos Strikes <br /> 440-5225(10/17/COM) <br />