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,F' 2. Manufactured Home Trip Permit Application <br /> �. _y • Department of Consumer and Business Services <br /> 4`� Building Codes Division <br /> 1535 Edgewater St.NW, Salem,Oregon •Phone: 503-378-4530 •Fax: 503-378-4101 <br /> Web: oregon.gov/bcd•Email: mhods.bcd@oregon.gov <br /> { <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:;INFORMATI.ON . <br /> Name:Factory Homes Clearance Center 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 <br /> ..1..,: _.. : .:-: .: ' ::' ,.. : ...: TRANSPORTER INFORMATION <br /> Nal-he:Phil Sterling <br /> Address (including city,state,and ZLP):17230 Beck Rd Dallas, OR 97338 <br /> Phone:503-932-2629 <br /> Email:philsterlingl@gmail.com <br /> . .. . . :HOME INFORMATION ` :: <br /> Home ID number(if known): DMV X-plate number(if)mown): <br /> Manufacturer:Fleetwood Model:Sandpointe Year:2023 <br /> HUD label numbers:ORE 560814 <br /> Serial number•s:FLE210OR23-23082A <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP):2655 Progress Way Woodburnd, 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 5C Salem OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: / •}'V fy <br /> J _.h Amount.:: '.. <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> .T.OTAL $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 0 Discover Phone:( ) <br /> Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> _v CBS <br /> (onsumerand <br /> Business Servkes <br /> 440-5225(10/17/COM) <br />