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s3 55 ) \rev Rd M 1211 , <br /> ": . Manufactured Home Trip Permit Application <br /> • Department of Consumer and Business Services <br /> 14; j:•' Building Codes Division <br /> 1535 Edgewater St. NW, Salem, Oregon o 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 /> =t r . , ' , AP,P�.ICANT,INFORMATIION : F <br /> Name:SUPERIORHOME TRANSPORT, LLC _. :..:. <br /> Address(including city,state,and ZIP):PO BOX 1067, JEFFERSON, OR 97352 _.. <br /> Phone`541-327-7805 <br /> Et fail RITAHARTZELL@GMAIL.COM <br /> TRANSPORTER,INFORMATIOlU $, <br /> , <br /> Name:SUPERIOR HOME TRANSPORT, LLC <br /> Address (including city,state,and ZIP):PO BOX 1067, JEFFERSON, OR 97352 <br /> Phone:541-327-7805 .- <br /> Email:RITAHARTZELL@GMAIL.COM - <br /> a. <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:SKYLINE Model: Year:2022 <br /> HUD label numbers: V <br /> Serial numbers:245-000-H-A101280AB <br /> ,ADDRESS INFORMATIOid .°,` s; <br /> Current location(including city,state,ZIP):550 SE BOOTH BEND RD, MCMINNVILLE, OR 97128 County:YAMHILL <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, stale,ZIP):5355 RIVER RD N, SPC 7, KEIZER, OR 97303 FE'ounty:MARION <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dealer nyire: - <br /> Applicant signature: <br /> AiYi Unti <br /> Trip permit(per section) $5.00(70511-1195) S <br /> $ <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 ❑Discover Phone:( ) <br /> Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> ` � CBS <br /> (onsumttand <br /> ...' Rushiess Services <br /> 440-5225(10/17/COM) <br />