|
, ' 4 S 8 D. 1-an ca 5V OR .
<br /> 8
<br /> Manufactured Home Trip Permit Application
<br /> 0�~ Department of Consumer and Business Services
<br /> ,r""�� 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 /> k _
<br /> 'e 5.� ikY.x s i rye i 2 a 1 r '� e '53.
<br /> x , �� ��.> � . ,�� �� h" :APRLI�A►�1T�IToI�ORlVii4Tft�l� > - � .' �,. �, � �:;>.� � , .k>...
<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 /> . . 's, . r-- ' -TRANSPORTER°'IN FORMATION '°
<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 /> l , :a ;HOME'IN' RMATION'
<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 /> k
<br /> 'r Y "-.., ,.s ..` :,° v '-` k AOI RESS 4INFORMATION. _' . < kJ .. . :
<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 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: (�b,�„,A;,„,,,a_ ( )7,pic_
<br /> Trip permit(per section) $5.00(70511-1195) $
<br /> nr, 14 &. . s,, ...1m , °;W.1.=TOTALS, $
<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 /> rt!'i °'-
<br /> BS
<br /> BusLiaskrvltes
<br /> 440-5225(10/17/COM)
<br />
|