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Date Sec Req'd: r~ -~--~ ? am/pm <br />Pack Date: am/pm <br />Delivery Date Req'd: 4--~'~`~] am/pm <br />Order Taken By: 'j'p~ <br />F ~~~~~a~ Ca~~ T~ar~~~~~ ~ , <br />'~+ 1465 Johnson St. M1lE, 5~:1em, OR 973t~(. <br />~jC~3) ~~l-F:,u3 • (800} g~~3-i~41 a fax (503) ~S?-692•T <br />PUC #G37342 ~ iCC MC 227345 <br />f {-,~ ~;- <br />HHG ~BILt OF LADING <br />' -f3ft. Number <br />36Ci <br /> ~ / <br />NAME ~ <br />NAME <br />Liberty H:~u~ar> liibert=,~ House <br />ADDRESS ADDRESS ` <br />'2'LJ Hi~h 5t P~r 2~:d Flour <br />~ <br />CITY STATE ZIP •~ L ~].~Cl y_ T . R' <br />CITY STATE ZIP <br />Salem t)regon S~:~e u~ Or~.ger <br />CONTACT PHONE CONTACT ` <br />PHONE <br />~8I11S2 CT~iWfOTu FAX <br />3/'~-Lf! <br />(j;~ <br />, <br />} FAX <br /> <br />I <br />I <br />I <br />I <br />~ START TIME: ~'{~p <br />J <br />I I I <br />I I I <br />I I I <br />I I I I I I I I I I I I I I I I I I I I I I I I I I <br />( I I I I I I I I I I I I I < <br />' <br />~ <br /> <br />6 AM 7 8 9 10 11 12 1 <br />2 3 4 INITIALS , <br /><;4 <br />am/pm <br />\, <br /> <br />NOON 5 6 PM FINISH TIME: 4 m y` <br />EXPLANATION: P-PACKING L-LOADING D-DRIVING UL-UNLOADING UP-UNPACKING X-TIME NOT CHARGED INITIALS "~''~~ am/pm <br /> <br />MATERIALS <br />MATERIAL <br />PACKINti <br />UNRACKING <br />AMOUNT ~ <br />IYtpyiNQ, <br />~rpTS <br />qT <br />{n <br />EXT <br />~_ _ __ .:. S~7'~ : fG4T~ QTY. R/!7E QTY. RATE .. 1 TRUCK & DRNER <br />BARRELS/DISHPACKS i TRUCK & 2 MEN ~y .~Cr ~ 1 i.r =, ; <br />CRATES/CONTAINERS EXTRA LABOR HOURS <br />CARTONS: 1.5 CU FT. 3Q 1. UU k' _ _ MATERIALS ~-: ,_ `F <br />3.0 CU FT OTHER <br />4.5 CU FT <br />6.0 CU FT <br />WARDROBE CARTON SUBTOTAL - <br />MIRROR CARTON , . , <br />MATTRESS CTNS: SiNG~e <br />DOUBLE <br />OTHER , <br />OTHER: .(~FE 1 2 . SO ~, ~';, -~ <br />e <br />_ .~ ~ ; _ f . AL - SUBTOTAI - <br />' • • <br /> . . <br />If the shipper declines to sign this declaration of arajae d the shipment is accepted DATE OF PICKUP REOUESTED DATE OF DELIVERY REQUESTED <br />the shipment will move at the depreciat~d 4alu~ pfQte~on level and the shipper wil <br />^ , <br />l <br />be subject to the appropriate valuation <br />eh8CE,JeS. SIGNATURElAGREEMENT TO HIGHER CHARGES DATE SIGNED <br />^ RELEASED VALUE PROTECTIOI~: <br />~ / <br />Good <br />ill b <br />l <br />e <br />6 <br />j ~ <br />~~ <br />s w <br />e va <br />ued at 60 cent~ p <br />j 1 <br />.,p~r ~riiele. , <br />1 <br />~'7~ ~' ~~1 ~ <br />Shipper. ,~, ~ , ,1; ;~ `'i Date: ~ GROSS WT. TARE WT. " NET YVT. <br />~~ ~~ <br />` <br />' <br />~ MILES: ~ . <br />^ DEPRECIATED VA <br />PROTEC~ <br />f10l~: Goods witl <br />be valued at $1.25 times the <br />actual w~ight 6f the shipment. Fo~' each $100.00, or fraction thereof, of declared value <br />at $1.25 times the weight of the shipment in ibs. or declared lump sum value, whichever CHARGES FROM ABOVE <br />is higher, the valuation charge shall be 50 cents per each $100.00 of value. OTHER CHARGES <br />Shipper: Date: <br />Lump Sum Value: STORAGE CHARGES <br /> <br />^ REPLACEMENT COST PROTECTION: Goods will be valued <br />t $3 <br />50 ti <br />h VALUATION CHARGES <br />a <br />. <br />mes t <br />e <br />actual weight of the shipment. For each $100.00, or fraction thereof, of declared"value <br />3 <br />TOTAL CHARGES ~ <br /> <br />~ <br />at $ <br />S0 times the weight of the shipment in Ibs. or declared lump sum value, whiChever ~:? <br />:~ ~l, __ . . <br />~ <br />is higher <br />the valuation charge shall be 85 cents per each $100 <br />00 of v <br />l <br />e <br />, <br />. <br />W <br />a <br />. <br />Shi <br />ADVANCE DEPOSIT <br />pper: Date: <br /> <br />Lump Sum Value: <br /> ~ BALANCE DUE~ r <br />~ <br /> <br />.. .. r <br />. <br />_; _ <br />.~. ~. <br /> <br />I acknowledge that I have received, at the first contact with the carrier, a copy of the C.O.D. ~$ILL PR EPAID <br />form entitied GENERAL INFORMATION FOR MOVING HOUSEHOLD GOODS OR RECEIVED IN,GOOD CONDITION EXCEPT AS NOTEp: <br />OFFICES IN OREGON which explains the Oregon rules and regulations affecting y <br />~ <br />intrastate shipments of household goods and office furniture and fixtures. Consignee '~~ ~` ~~~' y/'~ -~ <br />_..,,.:.r <br />I understand that my final charge for service must be based on rates that have been <br />_~..._ _- ,,I <br />~ <br />~ ~ <br />approved by the Public Utility Commission and published in a tariff regardless of any <br />estim <br />f <br />t <br />i <br />id <br />d Driver. - <br />~ <br />./ r---L, .S~l <br />` <br />a <br />e <br />or serv <br />ce prov <br />e <br />to me by the carrier. I UNDERSTAND THAT AN ESTIMATE <br />IS NOT A FIRM BID. COMMENTS/EXCEPTIONS~ <br />Dated: <br />Shipper: <br /> <br />Carrier: <br /> <br />r,~ ~,,. ....~.,-. wTe No. so <br />