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� B , , LQflCr �J9, ME `7 IN <br /> 3 Manufactured Home Trip Permit Application <br /> . Department of Consumer and Business Services <br /> ''`6i 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 /> 4imiii e ..... , T 1ar41 Y.4 3 b ke" : fi PP itC tNFORMAT +:"' V ..5 .:. <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 /> k # <br /> 1 1000:0 . i ; :> . TRANSPORTER INFORMATION <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 /> $ _ i.� k ie^' {■V QpR�M® n y. f r s .' <br /> pf.W e E.w.F-: hlr, i� .. .. € + �u�., ��'. !',�W�}�f���N�A� �/,ki��111'i����� � � .. ':k t _ ` a. . �i; .. � <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 /> f 4IAI'DDRESS,II+IFORNIATION , <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 /> g <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: <br /> Trippermit(per section), $5 00(70511-1195) $ <br /> . ,, E > , i-> , ki ,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 ❑MasterCard 0 Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> 1 <br /> Credit card number Expiration <br /> D. BS <br /> -'Com meea��a�n,.d. <br /> 440-5225(10n7/COM) <br />