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Manufactured Home Trip Permit Application <br /> Department of Consumer and Business Services <br /> N•-•'"0/ Building Codes DIvision <br /> ciA• <br /> 1535 Edgewater St.NW,Salem,Oregon•Phone: 503-378-4530 •Fax: 503-378-4101 <br /> Web: Oi:egon.gov/bcd •Email: inhgds.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 /> INFORMATION <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@guhnerlIc.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:philsterling 1@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 /> HUD label numbers:ORE 560829 <br /> Seti4numbers: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 /> 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 #11A Salem OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> El Oregon dealer lot Dealer name: <br /> Applicant signature: <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> $ago <br /> • <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 scud cash.Secure fax: 503-947-2333 <br /> 1:1 Visa D 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 /> lit CBS <br /> Consume/and <br /> Business Seivices <br /> 440-5225(10/17/COM) • <br />