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--}-_ __ <br /> zi38a tanca.51-tr DR k)E- 7 0 <br /> r <br /> '' Manufactured Home Trip Permit Application <br /> 7: Department of Consumer and Business Services <br /> • 'w 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 <br /> county at the <br /> gtime ofy certification.t� <br /> ; Is Y +, :i2 , €; ,. . .ARMAC!°1A111a#l1'#('iJI�MA ION': ,. ,' .?.• ,j.., 7:'.. <br /> Name:COMMONWEALTH HOMEOWNER SERVICES 3 <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 /> t .` .. _ TRANSPORTER INFORMATION t,, ;, ,., <br /> ri <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 /> m , n • 1::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 561306 <br /> Serial numbers:FLE2100R23-23251A <br /> :.; .,. ,,Rant,;,t.•. r '' AD►DRIESS,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.#70, Salem, OR 97305 County:Marion <br /> Manufactured home park name,if applicable:Starlite MHC <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: moo.-- t <br /> Trippermit(per section $5.00(70511-1195) $ <br /> .-'' u1 ..r ..ii xe1e.#,,..; j. . zndie', hOT ti.: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 /> 1BS <br /> Cmsumaaod <br /> &a4iess5errkes ' <br /> 440-5225(10/17/COM) <br />