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L8E3a, t‘ancg,s-c.c_v 3C0 <br /> 4- Manufactured Home Trip Permit Application <br /> Department of Consumer and Business Services <br /> Building Codes Division <br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530 •Fax: 50 - -gg 3 378 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 /> •'6d-•i�k'`k 7f6 * s l k i p CgNTFOR p *� rA 3., -t, £ €•;k el T\ r.�:Y <br /> �APPLIGAPI A�'.��9-�JIS�f'1T���IY. <br /> Name:COMMONWEALTH HOMEOWNER SERVICES <br /> Address(including city,state,and ZIP):18150 SW BOONES FERRY ROAD, PORTLAND, OR 97224 <br /> Phone:503-244-2300 <br /> Email:melisa.cook@cwres.com <br /> a . 'T NSPORTER:INFO TION :' <br /> Name:BENNETT TRUCK TRANSPORT, LLC <br /> Address(including city,state,and ZIP):1360 INDUSTRIAL WAY, WOODBURN, OR 97071 <br /> Phone:503-981-7939 <br /> Email:nancys.wbo@bennettig.com <br /> «'.. ,N • 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 561301 <br /> Serial numbers:FLE210OR23-23247A <br /> `AD©RESS=INFORMATION <br /> Current location(including city,state,ZIP):1360 Industrial Way,Woodburn, OR 97071 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):4882 Lancaster Drive NE, Sp.#36,Salem, OR 97305 County:Marion <br /> Manufactured home park name,if applicable:Starlite MHC <br /> ❑.Oregon dealer lot Dealer name: <br /> Applicant signature: <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> 3 4 v <br /> "T.OT • $ <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:( ) Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> r.. BS <br /> Calmer and <br /> Mies Smite <br /> 440-5225(10/17/COM) <br />