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lb <br /> 4Sncv L,an OP . lvL I 3 8 <br /> 141°',' Manufactured Home Trip Permit Application <br /> .a Department of Consumer and Business Services <br /> �t�1 Building Codes Division <br /> -1- 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 /> :01 ;s -. ` .;, < c , ','APPLICANT'INFORMATION ' .' ', ,,. "4 <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 /> TRANSPORTER-INFORMATION _' '' 3'f <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 /> : c a : a t 3 K ` 'HO ^, s .':;..' <br /> .. � . HOME INPOFiMAT1®Ill.'. . .'., ,� s <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:FLEETWOOD Model:SANDPOINTE Year:2023 <br /> HUD label numbers:ORE 561270 <br /> Serial numbers:FLE210OR23-23226A <br /> ;,¢ , s 6 ADDRESS INFORMATION,�� � . ;��. .. .�� � . ._ a . E r �:. <br /> Current location(including city,state,ZIP):1360 Industrial Way,Woodburn, OR 97071 County:Marion <br /> Manufactured home park name,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 Dr. NE, Sp.#138, Salem, OR 97305 County:Marion <br /> Manufactured home park name,if applicable:Starlite MHC <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: „ ,, C <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> .i T,I.F. -# ,"1 kP . X,u. ! ' ..TOTAL ? $ <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:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> F" <br /> ii <br /> �.�� BS <br /> Conner and <br /> auslfiess servto <br /> 440-5225(10/17/COM) <br />