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rat Manufactured Home Trip Permit Application <br /> m �r Department of Consumer and Business Services <br /> -e; Building Codes Division <br /> tl_sr <br /> 1535 Edgewater St.NW,Salem,Oregon•Phone: 503-378-4530 • Fax: 503-378-4101 <br /> Web: oregon.gov/bcd•Email: mliods,bcd@oregon.gov i <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.`' ' ' <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 /> Email:janetm@gunnerlic.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:philsterlingl@gmail.com <br /> ;.: <br /> HOME:INFORMATIO N ... ' ::.. • .:. , . <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Fleetwood Model:Sandpointe Year:2023 <br /> HUD label numbers:ORE 560803 <br /> 'Serial iiumbers:FLE210OR23-23071A <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 #18A Salem OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer nam <br /> Applicant signature: <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> TQTAL` $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 /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> IN; PCBS • <br /> (ammo and <br /> 8us41055evices <br /> 440-5225(10/I7/COM) <br />