Laserfiche WebLink
osql <br /> er---„\-- Manufactured Home Trip Permit Application (o b'13 4 5 <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: orcgon.gov/bcd • Email: mhods.bcd(u 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 /> APLIFORMATION <br /> _,-z"3� ,v''- . ",��". � .� ` � i _"`. -. -"PC,ANT�I 1.. ,..__ <br /> Name:SUPERIOR HOME TRANSPORT, LLC <br /> Address (including city.state, and ZIP):PO BOX 1067, JEFFERSON, OR 97352 <br /> Phone:541-327-7805 <br /> Email:RITAHARTZELL@GMAIL.COM <br /> TRANSP;ORTERINFORMATION ,.., ; <br /> • <br /> Name:SUPERIOR HOME TRANSPORT, LLC <br /> Address(including city, state, and ZIP):PO BOX 1067, JEFFERSON, OR 97352 <br /> Phone:541-327-7805 <br /> __� <br /> Email:RITAHARTZELL@GMAIL.COM <br /> • HOME INFORMATION"_Home ID number(if known):232749 1 DMV X-plate number (if/mown): <br /> Manufacturer:HOMETTE 1 Model:N/AI Year:1981 <br /> HUD label numbers: <br /> Serial numbers:03910174P-AB <br /> YADDRESS'INFORMATION <br /> Current location(including city, state,ZIP):950 AIRPORT RD SPC 23, ALBANY, OR 97321 County:LINN <br /> Manufactured home park name, if applicable:SEQUOIA ESTATES <br /> ❑ Oregon dealer lot Dealer name: <br /> ❑ Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state, ZIP):2091 KENNEDY CIRCLE NE j County:MARION <br /> Mauufaeturedhome park name, if applicable:KENNEDY MEADOWS <br /> ❑ Oregon dealer lot Dealer name: -_ <br /> ! Applicant signature: <br /> Amount <br /> Trip <br /> iP permit(per section) $5.00(70511-1195) $ <br /> T UTAI : S <br /> Make check or money order payable to Department of Consumer and Business Services. If paying by credit card <br /> , applicant <br /> credit card information box.Do not send cash. Secure fax: 503-947-2333 <br /> must sign I Pho <br /> ne: � <br /> Visa ❑MasterCard ❑Discover ( ) [-Department use only <br /> ❑ - P <br /> 1 S <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> } CBS <br /> Su4nns Seraces <br /> 440-5225 t 10:171COM i <br />