Laserfiche WebLink
a,0(o 8 1-<e.6 �eci cl-g_ me Coo , We <br /> p Manufactured Home Trip Permit Application rn. 3 5-i 3 5-1 <br /> f.tH , e Deportment of C'nnsnmer arid iiusiness Services <br /> l-‘-its Building Codes Division <br /> 1535 Ede hater Si. NW,Salem,Oregon•['hone:SO3-371;-9530•lux_SCA-:?7k 410I <br /> Web:oregon.govfbcd • Falai': Hinds.bcdt'a;oregotl.(,oy <br /> This application roust he submitted with a valid tax ocitilicatxm from the county in which the home is currently locum!, <br /> .1s Well its the county the home is moving to.A valid tax certification is one.;ltai'itus beencertified by the county and <br /> submitted before the expiration date provided by the county at the time of ectliftcation. <br /> APPLICANT INFORMATION _..._ <br /> Name:Amber Homes LLC � <br /> I address(including city',stale,and Itr]:201 Siem Court,Los Altos CA 94024 <br /> I Phone:253-221-3757 <br /> ktuail:dim <br /> are,am urhomesllot ail_cam _ _ <br /> _ TRANSPORTER INFORMATION <br /> Name:Doug's Mobile Hernei ransport _ . <br /> Address(Inc.ludii.lg city,state,and;CII' 121392 Fri Rd NE Aurora O:R:i7002 <br /> Phone-541-730-6191 <br /> Ii moi I:ctlorligirr75@ gmail.com <br /> _ .__. HOME INFORMATION <br /> Home a.)numhcr(rf;;,tr�wrrl t)�{V X-plate number I t1`ktlr7tr=r;lt <br /> blanttrticturcr:Fleetwood \ludi I I_G14GCl2S ££ 4'ear.2019 <br /> 1"l1 i D label numbers: <br /> Serial numbers;(LE.21s7OR19-19ti7f <br /> ADDRESS INFORMATION <br /> Ctrrrr,nt location(inducting city state /.tP):2CiES Progress Way,Vtroudburn, OR 97071 t Coontylviarion <br /> tilantdactwrd home j)ark name if applicable: <br /> fill Oregon dealer lot 1 Dealer name:l-Luetvvad <br /> ❑Out-of-state dealer lot Dealer roux.and contact information- <br /> __ <br /> Placement location(ineludine ctt' st rte ZIP) 206t3Kettretiiv Circle NE SPC>♦eO1 Ke;cer OR 97303.i C,nunty:Crackam <br /> 1.Manulttwtured home part:name, ti.it:iplrcablc_Kennedy 1,lw.tdarr; <br /> Oregon dealer lot I Dealer name: • <br /> 1ppl east signature, I _ <br /> a <br /> - <br /> Amount: <br /> ITriopeIntit(per section) _ S5 tn,)(70T51 I-1195) 55.0o <br /> }.. ____ :drat_ s <br /> Jake check or money order payable to Department of Consumer and t,usiiirxc tirrviccs.If paying by credit curd,applicant <br /> n11LS1 situ credit curd infmr-rnation bot'.Un not send coda,Sceuje aux:5O3.947-i333 <br /> U viva D.?.1z:;IcrCald j Dsseuscr t'iinni i I Deportment use only <br /> ,........___i <br /> r._. C:r.dlwlder SI Z1ILM ATTIOW11 1 <br /> I <br /> N'ztr.1.oCi-i.dht icrusshxvrtonenisfi;cald <br /> r <br /> Croiit c:-rd man:, Expiration <br /> ii DCBS <br /> T.te,,`.zs,r, <br /> ,r.t_1.52_25tItrllC N11 <br />