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'1 9 I, 5 e `I e R ) mt--- 4 <br /> Manufactured Home Trip Permit Application m 3 5 B 3 <br /> \N *-,i4.,;ftt'' Deart Building Codes Dons oner and Business Services <br /> n <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 /> _ _APPLICANT INFORMATION '• - `-'• . r,'' <br /> Name:Amber Homes LLC <br /> Address (including city,state, and ZIP):221 Main St.#2039 Los Altos, CA, 94023 <br /> Phone:253-221-1757 <br /> Email:clare@amberhomes.us <br /> TRANSPORTER INFORMATION; <br /> Name:Superior Home Transport, Inc. <br /> Address(including city,state, and ZIP):111 S 2nd StJefferson, OR 97352 <br /> Phone: 541-327-7805 <br /> Email: <br /> . HOME INFORMATION:;:.' :' _- <br /> Home ID number(if known): DMV X-plate number(f known): <br /> Manufacturer:Flettwood Model:Eagle Year:2019 <br /> HUD label numbers: <br /> Serial numbers:FLE2100R19-2848A13 <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):2655 Progress Way, Woodburn OR, 97071 County:Marion <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):49156Swegle Way NE,#74, Salem OR, 97301 County:marion <br /> Manufactured home park name, if applicable:Sunset Village <br /> ❑Oregon dealer lotealer name:Amber Homes LLC <br /> Applicant signature: �'get� _ <br /> .:Amount:: <br /> Trip permit(per section) $5.00(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 /> El Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> 'O DCBS <br /> 8 9 <br /> i < Consumerand • <br /> / 5usinessSerrices <br /> 440-5225(10/17/COM) <br />