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C <br /> L61 / � Sk i I A S�� �� <br /> Manufactured Home Trip Permit Application <br /> Department of Consumer and Business Services <br /> Building COdes Division <br /> 1535 Edgewater St.NW, Salem,Oregon•Phone: 503-378-4530 •Fax: 503-378-4101 <br /> Web: oregon.gov/bcd•Email:mhods.bcd@oregon.gov <br /> This application must be submitted with a valid tax certification from the county in which the home is currently located, <br /> as well as the county the home is moving to.A valid tax certification is one that has been certified by the county and <br /> submitted before the expiration date provided by the county at the time of certification. <br /> Name: Factory Expo Homes <br /> Address(including city,state,and ZIP): 2555 Progress Way,:Woodbum, OR. 97071 <br /> Phone: 503-981-0770 <br /> Email: moconnell@factoryexpohomes.cdm <br /> TRANSPORTER.INFORMATION <br /> Name: Superior Home Transport <br /> Address(including city,state, and ZIP): PO Box 1067,Jefferson, OR. 97352 <br /> Phone: 541-327-7805 <br /> Email: <br /> HOME.INFORMATION <br /> Home ID number(if known): DMV X-plate number(if-known): <br /> Manufacturer: Fleetwood Model: Quartzville 28583R year: 2019 <br /> HUD label numbers: <br /> Serial numbers: FLE210OR19-20012AB <br /> ADDRESS.INFORMATIOPI;.. . '. ;:, <br /> Current location(including city,state,ZIP): 2555 Progress Way,Woodburn OR. 97071 County: Marion <br /> Manufactured home park name,if applicable: <br /> I]Oregon dealer lot Dealer name: Factory Expo Homes <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP): 18716 Shirley Ave. Hubbard, OR. 97032 County: Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: 744e9,761 t ,,,12--),,91( <br /> ;Amounts, <br /> Trip permit(per section) 55.00(70511-1195) $ <br /> TOTAL . < $ <br /> Make check or money order payable to Department of Consumer and Business Services.If paying by credit card,applicant <br /> must sign credit card information box.Do not send cash.Secure fax:503-947-2333 <br /> ❑Visa 0 MasterCard 0 Discover Phone:( ) <br /> . Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> ADL,[ CBS <br /> '34 Coaumaand <br /> Busine3 Sen'Ites <br /> 440-5225(I0/17/COM) <br />