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Date Ser. Req'd: - am/pm Capf~al City Transfer <br />« HHG BILL OF LADING <br /> R -- am~pm . <br />1465 Johnson St <br />NE <br />Salem <br />OR 973~~ ~ '` <br /> Delivery Date Req~d: - - ~:~= /Pm . <br />, <br />, <br />( Q3? 5~ }-~:~3 • t800j ~23-1641 • fax t503) 58i -6924 B/L Number <br /> <br />omer Taken ey: <br />PUC #03T3~42 • 1CC MC 227345 ~ <br />;'J~,,, _ l~+c'' X"~~ <br />- <br />, ~ ~ <br />- - <br /> <br />NAME <br />ADMINISTRATIVE SERVICE-MARION COUNTY . <br />NAME <br />.ADMINISTRATIVE SERVICES-MARION COUNTY <br />ADDRESS <br />220 HIGH ST 4th FI.OOR <br />CITY STATE ZIP <br />5~~ ~~ ADDRESS <br />-_ Cj -- /t ~ <br />CITY ' E ZIP <br />CONTACT PHONE <br /> <br />ELYN LYONS F,vc CONTACT J N~ y <br />J` <br />F,~ <br /> <br />l ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ C. J S <br />~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~~ I IN TART TIME: <br />ITIALS <br />/ <br /> <br />6 AM 7 8 9 10 11 12 1 am <br />pm <br />2 3 4 5 6 Pti1 FI <br />NOON <br />EXPLANATION: P-PACKING L-LOADING D-DRIVI UL-UNLOADING UP-UNPACKING X-TIME NOT CHARGED IN NISH TIME: <br /> <br />ITIA~S am/pm <br /> <br />1~E~~At,S , <br />~ <br />'~IAL <br />PACl~IN~v <br />1~'t <br />AMOUNT • <br />MOYlNt~ <br />UNi7S <br />!; RT . <br />#~1'. <br />~7(T. ' <br />' QTY. RATE QTY. RkTE .. RA'['E" k 1 TRUCK & DRIVER S4. E S ' 1 ~, <br />BARRELS/bISHPP(CfC'• . ', • <br />. <br />, <br />,''` ~ <br />Y <br />` " <br />°~ <br />s~ < < : <br />TAUCl~ & 2 MEN + <br />. _ <br />>:° <br />, a <br />. .,_ <br />CRATES/CONTAfNERS EXTRA LABOR HOURS <br />CARTONS: 1.5 CU FT. 1 SO ~. O ,~ ,~.J MATERIALS <br />U <br />3.0 CU FT !' OTHER <br />4.5 CU +. .~ . - <br />6.0 CU FT r (` ~ _ <br />WARDROBE CARTQN ~ ~~~ ~'~~. <br />MIRROR CARTON a • ~ <br />MATTRESS CTNS: s~NG~E <br />DOUBLE <br />OTHER <br />OTHER: TAPE S Z.SO ~ ~ ,,r~y <br /> N/C <br />SUSTOTia-l.' - <br />. .-• • • . <br />If the shipper declines to sign this declaration of value and the shipment is accepted, <br />the shipment will move at the depreciated value protection level and the shipper will SiJBTtTF'rA~... -, <br />. . ~ . <br />DATE OF PICKUP REQUESTED DATE OF DELIVERY REQUESTED <br />be SUbJeCt t0 th@ BpPfOpflBte V31U8tlOn Ch8~98S. <br />^ RELEASED VALUE PROTECTION: 51GNATUREtAGREEMENT,TOHIGFtERCHARGES DATE SIGNED <br />, , ~ ' , , <br />Goods will be valued at 60 cents per Ib. per article.. <br /> <br />Shipper: D <br />t <br />6ROSS WT. T~CFtE 4YF. NE I` y <br />{~IF. <br />a <br />e: <br />MILES: @ <br />^ DEPRECiATED VALUE PROTECTION: Goods will be valued at $1.25 times the <br />actual wei <br />ht of the <br />hi <br />ment <br />F <br />h $1 <br />0 <br />00 <br />f <br />ti <br />h <br />f <br />f <br />g <br />p <br />s <br />. <br />or eac <br />0 <br />. <br />, or <br />rac <br />on t <br />ereo <br />, o <br />declared value <br />at $125 Cxnes the vu$igH[ of the s~iprtieM in"Ibs. or deClilred IOmp sum'4al~g, whicheder CHARGES R_ <br />~~~~E - <br />is higher, the valuation charge shall be 50 cents per each $~00.00 of value. OTHER CHARGES <br />Shipper: Date: <br />Lump Sum Value: STORAGE CHARGES <br /> <br />^ REPLACEMENT COST PROTECTION <br />G <br />d <br />ill b <br />l VALUATION CHARGES ' <br />: <br />oo <br />s w <br />e va <br />ued at $3.50 times the <br />actual weight of the shipment. For each $100.00, or fraction thereof, of declared value <br />#f at $350 times the weight of the shipment in Ibs. or declared lump sum value, wCichever <br />- <br />fs highef <br />aluation ch <br />r <br />h <br />lt~b <br />85 <br />~ <br />106 <br />00 <br />f <br />ai~ <br />-{~'~aL ~H~R{~+~~ ~ <br />~~^ <br />;~ d''f ~~..~ <br />. <br />, y <br />ge s <br />a <br />a <br />e <br />ce <br />s per each $ <br />. <br />o <br />v <br />e. <br />~R ~,,J <br />ADVANCE DEPOSIT <br />Shipper: Date: <br />Lump Sum Value: <br />. „ .. . . ~~~~ p~~~ <br /> <br />, , <br />I acknowledge that I have received, at the first contact with the carrier, a copy of the C.O. D. x BILL ~ PR EPAID <br />form entitled GENERAL INFORMATION FOR MOVING HOUSEHOLD GOODS OR <br />OFFICES IN OREG~N which explains the Oregon rules and regulations affecting <br />intrastate shipments of household goods and office furniture and fixtures. RECEIVED IN GOOD CONDITION EXCEPT AS NOTED: <br /> <br />Consignee: <br />I understand that my tinal charge for service must be based on rates that have been <br />approved by the Public Utility Commission and published i~ a tariff regardless of any <br />Driver: <br />estimate for service provided to me by the carriec I UNDERSTAND THAT AN ESTIMATE <br />IS NOT A FIRM BID. <br />Dffied: COMMENTS/EXCEPTIONS: <br />Shipper: <br />Carrier. ' <br /> <br /> WTB NO. 50 <br />