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- -, ; gg15 5weoI-e. Vol NI 1T/nQt 3C(,I,eilirN. <br /> r-%/11 <br /> ( : MManufactured Home Trip Permit Application M 35 `7 4 I 1 <br /> .(cgic .,:r Department of Consumcr•tmd Business Services <br /> �`~~• JI Building Codes Division <br /> � y - IS'35 L•dge.walcr St NW,Salem,Orcvnn•Phone:503-378-15311•Fax: SU3.373-1101 <br /> Web:oregon.gav:bed• Elnai.i; niltads.badgorcgan.gov <br /> This application tttus1 be submitted with a valid tax certification from the county-in y4htchtiff l,imtc is c•urmnTiy;vratt c1,. <br /> rs well as the county the ham:is moving to,A valid tax et:rtilicaliiin is r>ito That has heen,cenificd by t:e county and <br /> submitted bcforc the'expiration date provided:by iltr:county at the time oNati iitcation. .! <br /> •_• • . ;APPL'ICANT..INFO.RMATION : ..•v ' . :•• • z".:/'-' �._ <br /> • <br /> Name'Amber Homes LLC __ Jl _ __. •. <br /> Address.(including <br /> (includingcity,state,and ZIP):201 Silvia Court.Los Altos CA 94024 <br /> + Mr , <br /> Phon::253-221-1757 <br /> _ • .— __. <br /> Fmail:elare.amberhomesIlc mail.cot <br /> _ <br /> : TRANSPORTER INFORMATION <br /> • <br /> _Nantc:Dcrug's M•abile Home Transport <br /> _ <br /> Address(including city,state.and 7.(P):12E392 Fry NE,A.utora,OR 9`7002 <br /> Phone:541.73_0-_6191 _^ _ ..__ __ _ ._... _ <br /> Lni til:charliglr195@gmsii.cx_�m _ <br /> �— "' J` HOME INFORMATION <br /> . • <br /> l tome iD number(ff krrown): - I.)41V X-piste number(i/krtnr4t). __- --r— . <br /> htanufat•It)Ier:S�:y1rIe. ....____ _._� ._� __.. ...... ,t <br /> • � s�dcl:l?.33 0l _-��'car:2J19 <br /> - (IUD-)label numbers: _ _. - -- <br /> Senut nuntbe:fs:bz•91-08465--l-a,bz-9;-G-646-1-b _ _ _ r . <br /> - ��-`�~ _ M ADDRESS INFORMATION -----_ <br /> Current Icrerttirytt(meh:ding.cily.stifle.Z1P):55U boat bens rd.Mornlnville OR 97128 i, Cotlntv:Yamhill` - <br /> hlanuf:tcturedborne park;name,:f npplicable: __- —_- - g <br /> :tits Oregon dealer lot Dealer narrtt:Sklytyne _ . . <br /> (-.1 Out-of-stun:dealer lot Z Dealer name and contact inft;rrtttlti(rn. <br /> • <br /> Placement location(includin.eitY,stctlt'.ZIP)-4y'l5 Swegle Rel.NE 468Sale:11'0R 97301 - 1 Counts/4M <br /> Manufactured home park narni%i1 a plicable:Ke_nnedy MeadO $ ---- - <br /> I-l Urrgon dealer tot , Dealer natio: •- <br /> tplic:tnl xi;nttlurc:l I'1,V,{ tt ,•,�� 1r _ ,-'_ • _..._ <br /> Ljry ---/Li V l Artioiinti : <br /> [Trip perinit (per section} S• S.(10(70511-1195). S5_00 • <br /> , M -•-�• ,.• • 'TOTAL ' $ <br /> 31nkc cheat or money order payable to Department of Con.cnnier and Business Soviet-s_I f paying by credit card,urplict.nl <br /> must sign crc<li1 curd tulortnITtlUn hos.Do onto trod rash,Secure fax:5113-91"4333 __ _—_-__._--." <br /> I0 v,,,, 11!Ads:crC._J 0 Lhuo r Phone:(^ ) _.__ Dt parrmtnt use only <br /> 11 $ 1 . <br /> j C h.�h`.c <br /> dr signature ,tn:uut51 <br /> ur-,r nr curttk,.•+Iticrai <br /> ivshOwn,m:a<dti cat • <br /> t <br /> Crcdii crud tntmbs I?xpiration ._J <br /> :D <br /> CBSS . • <br /> .t.10.52:.t.rtnqTdt'OM} <br />