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<br /> ,/',6`1a'. Manufactured Home TripPermit Application 60 `7 -d
<br /> ` ' , Department of Consumer and Business Services
<br /> +a Building Codes Division
<br /> 1535 Edgewater St. NW, Salem, Oregon • Phone: 503-378-4530 • hax: 503-378-4101
<br /> too - IN Web: oregon.gov/bcd • Email: mhods.bcd(4),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. '
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<br /> �r . �. ; ;w k ,s Non r ' �,APPLICAAIT INFORMATIONk r �, , c, , : tt a 0 c, n x;
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<br /> Name: Joe.Rubino
<br /> Address(including city, state,and ZIP): 280 15th st ne satem oregon 97301
<br /> Phone: 971-338-6477
<br /> Email: j2.prpbusinesssolutions@gmail.com
<br /> : " 'T: ' TRANSPORTER:INFORMATION z , u £` '
<br /> Name: Bennett Trucking
<br /> Address(including city, state,and ZIP): 1360 Industrial Way, Woodburn, OR 97071
<br /> Pltonc:(503) 981.-7939
<br /> Email:wbo@bennettig.com
<br /> '� t r+ v � AI"'�+" � � �°��$ <4 7 ag+�" :"`` - x• x}t"{• `c��.&�+.vx� •'rE v, ��4 tt,5.'�2 '„"ems . 3
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<br /> Home ID number(if known): DMV X-plate number(if known):
<br /> Manufacturer: Fleetwood Homes Model: 28483U Pure Year: 2024
<br /> 1-LUD label numbers: ORE563790 &ORE563791
<br /> Serial numbers: FLE2100R24-23958A ...
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<br /> `,`r. ,r?``' c 1 :P .> ���.,.;K. `_ j ,.., ;�; ADDRESS 1t .FORMATIONA I ? �� a '; b. r,
<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: Park Model Nation LLC
<br /> El Out-of-state dealerlot Dealer name and contact infoiination:
<br /> Placement location(including city, state,ZIP): 100 E Central Ave Gates Oregon County: Marion
<br /> Manufactured home Sark name, if applicable:
<br /> ❑ Oregon dealer lot D aler name: Park Model Nation LLC
<br /> Applicant signature:
<br /> ount rt 4 A:
<br /> 1 _Trip permit(per section) S5.00 (7051 11195) S
<br /> Ta U°t,^"nam..:,?;'x�k>#:t«ieS.tdtTOTI!LW $ ' 0.
<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 /> l]Visa ❑MasterCard El Discover Phone:( ) Department use only
<br /> VE " $ new Y ome
<br /> Cardholder signature , ,. Amount
<br /> Name of cardholdertiaS shown on credit card
<br /> Credit card number Expiration
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<br /> ?us:-ms Sm1us
<br /> 4,10.5225(10/17iCOM1)
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