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4 .9 15 cj I-e ?ci M e *-Ion i 5 ct,1,0 1-v-... <br /> i.,ti`-),.?;*t• Manufactured Ionic Trip Permit Application M 35 111 11 <br /> ,eti- <br /> ,, .,;� - .-fE'� [)epariment nt Consumer-and nntl Bu.�iitcss Services <br /> \-.•,-,-v, ,, Building Codes Division <br /> `-:2. , <br /> 1535 Edgewater St NW,Salam-Ore. nn•Phone: 503-3784531I•Pax: 5.03-3784101 <br /> Web;nregotl.gov/bed•Email; mhtiods.hcdfOorcgon.gov <br /> 'Illis.application must be satrbmitteu with a valid tax certification Bum the comity'in winch th,x home is currently located,. <br /> as well as the county the hone is:r virg to,A valid tax c.ertiiication is one.that has heen.eatirtcd by the cotunty and <br /> submitted before the'expiration date provided.by the county at the time of certification.' <br /> • ;APPLICANT�INFO.RMATI_ON - <br /> I. • <br /> Namc';imber Home LLC <br /> Address'd•inctudin_city,state.and ZIP}:20 i Silvia Court.Los:'ultr;sa CA 94024 <br /> Phone:253.221-1757 _ _ <br /> — - <br /> (-nail:clary.arnb6thomeslledgmail.carra _—_�_._ — .._ <br /> TRANSPORTER INFORMATION <br /> `tun^Doug's P,<.ibaleNt�r e 1 ranspot E <br /> t. �city.state. fl�j 12(ry 'Fry Rd hlt ,;9.urc�r OR t ?(#U2 <br /> hone:541-730 <br /> lldilrwv including art �1ate tiYd/- <br /> 1 <br /> ' 6 i-- <br /> € . tl.chartigiri05���gma:i.nonr _ __ z <br /> �_ _ HOME INFORMATION <br /> lutne it)number(flknown): `— II)4.1V X-pi.ite number i,tj�arni•_�a)�__ ._...---- _ <br /> h•ianuiactirrer S,ylne ___--- _ >`totie1:1r33 et __� , 1't:;r,2g19 <br /> - 11[31)label numbers: __ <br /> Serial oto t ars b7-?1-064,34-a,bz-9'; (i664ti-r-b — _ <br /> ADDRESS INFORMATION <br /> Current location(includ n criv stab %.,1P):550 booth bend td.Mc iiinnlle OR 971213 _ ._. Coenty Y3mh UI <br /> Mann actured homclark rano.if,arppIical)1, _ -_. - �__ .._._ <br /> (Yregon dealer lot I>c.aler nsrue Sklvfrte __ _ .. - ___._ _ <br /> H Out-of-state dealer hot Dealer name and contact nft natation <br /> :Placement location(ruche ins city,stats 7,11'1 4915 Swegle Rd.NE 460 Salem OR 97301___._. C.ount�:Maron _---.. <br /> hl:i iufactureo home bark n:lrrie,it applicable:Kcraned ivleado`,es =__ <br /> . I-7 O cgt n dealer tot I Dealer name: <br /> ____�__ -__. _ _._ _ __—___. _ — <br /> A plieZlrtt signature:9 tIT , _. - '--- <br /> _K <br /> Aniount `: <br /> 1 <br /> Trip pscanit Ike it etion} S5till 17:0St 1-t 195) 'FAG <br /> i __ � . 'TOTAL; �S.. _ _ <br /> Nlakc check,or money order payable to Department of Cons-tether and Business Servire_s-If payint by credit card, q ptieuut <br /> must sign cr r4itcurd information boss I)o_ut t sant'cash.SSecure fax:5113.947-2333 _ <br /> Iu V:ra C L1u:;icrC:.-J Li D: ver Ph,nr:( 1 Department use only---���—` - <br /> C dh..Lf- si mature An_ouni <br /> Nara:Of catttl°hokicr as lliown,nr seed i 1111111 <br /> i <br /> rrdit card rilnmb*s I ix;i <br /> C` t tion <br /> • <br /> CCBS <br /> 2s,,-.1,:ntaS4 <br /> :til'.>2L`.tlft,PCOM? <br />