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-D:x56 La,nciL5)-ey Or 0 - 6 6065 04 <br /> , <br /> rai. �, Manufactured Home Trip Permit Application <br /> " :, , Department of Consumer and Business Services <br /> ^ <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: mhods.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 /> :. APPLICANTINFO.RMAT:IO.N °:;::" <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@gunnerlic.com <br /> TRANSPORTER INFORMATION <br /> Name:Phil Sterling <br /> Address(including city,state,and ZIP):17230 Beck Rd Dallas, OR 97338 _ <br /> Phone:503-932-2629 <br /> Email:phsterling1@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 560452 <br /> Serial numbers:FLE2100R22-22968A <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 /> D 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 SE#8B Salem, OR-07396 q 7 3 11 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer nalne-',• <br /> Applicant signature: `• \ <br /> l ' Trip permit(per section) $5.00(70511-1195) $5.00 <br /> TOTAL $5.00 <br /> Make check or money order payable to Department of Consumer and Business Services.If paying by credit card,applicant <br /> must si a credit card information box,Do not send cash,Secure fax: 503-947-2333 <br /> ❑Visa 0 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 /> t JCBS <br /> `�.,'� Consumer and <br /> Wien Senkes <br /> 440-5225(10/17/COM) <br />