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r Ace•14 0o3 30 <br /> Lam u'eN Manufactured Home Trip Permit Application Om s �3�1) <br /> :, Department of Consumer and Business Services <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 /> APPLICANT INFORMATION <br /> Name:Amber Homes LLC <br /> Address(including city, state, and ZIP):221 Main St#2039, Lot Altos CA, 94023 <br /> Phone:(210)692-4249 <br /> Email:inventory©amberhomes.us <br /> , TRANSPORTER INFORMATION <br /> Name:Superior Home Transport LLC <br /> Address(including city, state, and ZIP):111 SOUTH SECOND STREETJEFFERSON, OR 97352 <br /> Phone:(541) 327-7805 <br /> Email:ritahartzell©gmail.com • <br /> HOME INFORMATION <br /> Home ID number(if known): 1\.) f (4_ DMV X-plate number(if known): <br /> Manufacturer:Fleetwood Model:Weston Super Value Year:2022 <br /> HUD label numbers:ORE 557393/94 <br /> Serial numbers:FLE210OR21-22051 NB <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 /> El Oregon dealer lot Dealer name:Fleetwood <br /> El Out-of-state dealer lot Dealer name and contact information:Placement location(including city, state,ZIP):4915 Swegle Road NE, Lot 63 ,5cjer„i, bfR `- 301 County:Marion <br /> Manufactured home park name, if applicable:Sunset Village <br /> ❑ Oregon dealer lot Dealer n me: <br /> Applicant signature: / <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> TOTAL .. $ <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 send cash.Secure fax: 503-947-2333 <br /> ❑Visa ❑MasterCard ❑Discover Phone:( ) <br /> Department use only <br /> . $ <br /> Cardholder signature Amount <br /> 'Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> r <br /> "'i Consumer and <br /> ( DCBS <br /> Busi Services <br /> 440-5225(10/I7/COM) <br />