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4-- <br /> 4 B 8 D Lancets DE1 ai <br /> ;;; <br /> j. 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: 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 /> ,. :'. .: , ,. ; . ,''APPLICANT INFORMATIOI : . '. , - . , g-., <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: <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 /> »A }, " ; ',t; . , . . ,: HOME IN'FORMATION:. . <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:FLE21 OOR23-23224A <br /> „ r. `.° °x. ,. ., . DDRESST`IVFORMATIOM . ,.. *: <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.#81, Salem, OR 97305 County:Marion <br /> Manufactured home park name,if applicable:Starlite MHC <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: a}.J--�x�.. <br /> 'i Amount:°,a 3( <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> TOTAL .F $ <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 /> ,, Consume/and <br /> ---';1 <br /> BustasSenices <br /> 440-5225(10/17/COM) <br />