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an ci 3R. E 14 .a <br /> ?`�. Manufactured Home Trip Permit Application <br /> ;j' Department of Consumer and Business Services <br /> V.s.� 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 /> a. 74 ;`ti 4 , 3 -;'r b, t, . A'APPLICAi4T-INFORMATION . ae , ', . f,. _ .j° _ ki <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 /> :' ' r , :`z :. 'm TRANSPORTER`INFORMATIOfd , ` , , .a, , ,x< ., <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 /> X, :. <:a <br /> :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 561267 <br /> Serial numbers:FLE210OR23-23221A <br /> i.:ADDRESS,'INFORMATION <br /> Current location(including city,state,ZIP):1360 Industrial Way, Woodburn, OR 97071 County:Marion <br /> Manufactured home park name, <br /> e if applicable: <br /> 0 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.#142, 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 /> _ ,, ._ ,. ;TOTAL a,. $ <br /> R <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 /> El Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> Cnsamerand <br /> iCBs <br /> Bu <br /> 440-5225(10/17/COM) <br />