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.a._O 53 Vennet�j q g mg- g Co , Wseiz .r ' <br /> 2..„1::*, Manufactured Home Trip Permit Application nel3 5-1353 <br /> fs,,:' ,ray a-t • <br /> W,_-_,..1 Department or Consumer and Business Services <br /> q1 Building Codes Division <br /> 1±35.l:dpc:saater St. tile,Salem,Oregon•Phone: 503-37S-4530• Fax: )03-31 -4101 <br /> Web: orcgun:goy/bed • Nail: mhads.b. l c,oregori t ov - <br /> 'Fits application must he suhnitfted with a valid tax Certification ham the county in which the bor)_;;is curtvnlIy'located, <br /> as well as the county the borne is moving to.A valid LIN certification is in that has been eertit^:ed by the County and <br /> suhn:in:dbefore the expiration date provided by the counts;at the time of Certiticattnn, <br /> APPLICANT INFORMATit)N <br /> None Amber Homes lLC <br /> Address(including city, state,and"1.11'):2111 Silvia Cour.Los,"Alas CA 9402.4 <br /> Phor:c.:253.221-1757 __. _ <br /> lame:i-ct;ire.amberhomesllct'rtgmail.com j <br /> _._. • --- _w <br /> _ TRANSPORTER INFORMATION y_ <br /> Name-noon's Mobile Home Trur�sport __., _. b <br /> Address(ittelniiing city stale,and Z:IP) 12692 Fry Rd NE Aurora OR.97002 <br /> a_ <br /> Phone:5,11-731?-6191 __� �._ w_, <br /> Emarl:cheigh195, gmait.om <br /> HOME INFORMATION <br /> Ilcxre I1)number(tf kn w,1), _.,_._,....__ +DMV X-piate number Ci f known) <br /> Manutiteturcr-Fteetwood Mocl 1 EG14GOi2S Year:2019 <br /> 1-IUD tahel numbers: <br /> Serial nuntbcrs_FLE21C•7F219-10G70 <br /> ADDRESS INFORMATION _ <br /> Current location tincludmg crty state_1W)_7b55 Progress Way.Wuodbum,CR x9707 � C sena t hi-anon <br /> Manufactured home pack name,ieapplic.able.: <br /> 1 aern dcaicr)oiL)eah r name:Fleur twood <br /> 0 Out-of-state dealer lot Dealer name and contact ink:l n ation: - <br /> Placement Icy ttnn tinc.tudirto City,State,GtP) 2053 Kennedy Circle NE SPC K 1G Keizer OR 97303 1 County Cla _mas <br /> '. anufactured borne nark melte if applicable:Kennedy Meadows <br /> 1�I Oregon dealer lot aaler i true: <br /> Applicant signature_ {LIZ�� f=• <br /> i _Amount:,. <br /> 1 Trip peirmrll(jrcrsection) $4 0n(70'ii11 11y5) .90 7_—w- <br /> Make cheek Or mune\order pityable to Dom—anent of Consumer and Business Servicci.if paying by credit card,applicant <br /> • must sign credit card infornutition box.t)o nut send aisle,Secure fax:j43-')47-2333` <br /> Ct visa iiNtao. 0 fr <br /> aatCsrac.,: s, : t`hi rc l: 'i <br /> __ ._______ Depart C)clxirtnrr.mr Use'only <br /> _ $ <br /> • <br /> Card1-akin stgnaturc _..._w Araut nl <br /> - j <br /> Nang..cif i- rjhol&r as Qiawn un cTotjt'ed <br /> . <br /> ._._-_ i_Ft,tIY t.al(t Haulier . _.—...._t 6(ltr t.f"ell __r <br /> „,.^r. Htii.., <br /> 4.:,..52.7 5 t sit i''.;',C 5M1 <br />