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y <br /> Manufactured Home Trip Permit Application b 5 a`C° <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/bed • 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 /> . i4 si d t t i ,i. APPLICANT-INFORMATION. " <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 /> EmaiI:RITAHARTZELL@GMAIL.COM <br /> r <br /> TRANSPORTER "1;w _ •`j , � ,i.., <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 /> . , .7,.. .S e ,x:. .HOMSINFORMATION _." <br /> Home ID number(if-know,,): ! DMV X-plate number Of known): <br /> Manufacturer:FLEET►NOOD HOMES 1 Model: Year:2022 <br /> HUD label numbers: <br /> Serial numbers:FLE2100R22-22624AB <br /> ,. _ ,-; ' -` = °;ADDRESS INFORMATION, ° Y - _ <br /> Current location(including city,state,ZIP):2655 PROGRESS WAY,WOODBURN, OR 97071 County:MARION <br /> Manufactured home park name, if applicable: <br /> p Oregon dealer lot 1 Dealer name: <br /> D Out-of-state dealer lot I Dealer name and contact information: <br /> Placement location(including city, state,ZIP):197 CLEARWATER AVE NE, SALEM OR 97301 County:MARION <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: Q , <br /> r _ i <br /> _ A11ii okl <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> .' ,.,`1; 0fr ) ' x . TOTAi.,4.-' $ <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 0 MasterCard 0 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 /> si Pi BS <br /> amines sev,as <br /> 440-5225(10'I7,COM) <br />