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<br /> 1:7,., Manufactured Home Trip Permit Application o P5
<br /> �, Department of Consumer and Business Services
<br /> BIANuilding Codes Division
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<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 /> g ' '.. :n' ., . APPLICANT INFORMATION° 3,b.
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<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
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<br /> Home ID number(if known): DMV X-plate number(if known):
<br /> Manufacturer:FLEETWOOD Model:SANDPOINTE Year:2023
<br /> HUD label numbers:ORE 561267
<br /> Serial numbers:FLE2100R23-23221A
<br /> - a :,,. ,,.,. ,.... ADDRESS INFORMATION' ' . :,.
<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.#142, Salem, OR 97305 County:Marion
<br /> Manufactured home park name,if applicable:Starlite MHC
<br /> ❑Oregon dealer lot Dealer name:
<br /> Applicant signature: U1,c�
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<br /> Trip permit(per section) $5.00(70511-1195) $
<br /> ,:r .-i s+ 7 !, 1 QtAI..;a..:: $
<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
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<br /> Credit card number Expiration
<br /> VainiComminesPswidtesetSand
<br /> 440-5225(10/17/COM)
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