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_ 49, 15 <br /> L loc s p 69 A-- <br /> Manufactured H5ome Trip Permit Application <br /> Department of Consumer and Business Services <br /> Building Codes Division <br /> • <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 /> ,•• APPLICANTJNFORMATION <br /> Name: Amber Homes LLC <br /> Address(including city,state,and ZIP):330 Rayford Rd, Unit#312, Spring TX 77386 <br /> Phone:248-842-8141 <br /> Email:marabeth.zielinsky@amberhomes.us <br /> TRANSPORTER INFORMATION :; ° <br /> Name:Bennett Transport <br /> Address(including city,state,and ZIP): <br /> Phone: <br /> Email: <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(f known): <br /> Manufacturer:Clayton Model: Dream Year:2024 <br /> HUD label numbers:NTA2216670/NTA2216671 <br /> Serial numbers:ALB043022 <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):1437 Century Dr NE,Albany, OR 97322 County:Linn <br /> Manufactured home park name, if applicable:NA <br /> ❑Oregon dealer lot Dealer name: <br /> 0 Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):4915 Swegle Rd Site 69A County:Marion <br /> Manufactured home park name, if applicable:Sunset Village <br /> ❑ Oregon dealer lot Dealer name: <br /> Applicant signature:Marabeth Zielinsky tud i ,Ze.44, <br /> Amount <br /> Trip permit(per section) $5.00(70511-1195) $10 <br /> TOTAL $10 <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 /> E Visa ❑MasterCard ❑Discover Phone:(248) 842-8141 Department use only <br /> lrvttrse0,,2iedfedt $10 <br /> Cardholder signature' Amount <br /> Marabeth Zielinsky <br /> Name of cardholder as shown on credit card <br /> 4148460007773675 <br /> 04 /28 <br /> Credit card number Expiration <br /> DCBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />