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431T1ühdS t <br /> , mrfe,% Manufactured Home Trip Permit Application 01, <br /> L35'657 ? <br /> �, '�`"�' y' Department of Consumer and Business Services j'Y <br /> Building Codes Division <br /> its <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 <br /> Name: Factory Expo Homes <br /> Address (including city, state, and ZIP): 2555 Progress Way,Woodburn, OR. 97071 <br /> Phone:503-981-0770 <br /> Email:moconnell@factoryexpohomes.com <br /> TRANSPORTER INFORMATION <br /> Name: Superior Home Transport, LLC <br /> Address (including city, state,and ZIP): PO Box 1067, Jefferson, OR. 97352 <br /> Phone: <br /> Email: <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer: Fleetwood Model: Honeydew 14441V Year: 2020 <br /> HUD label numbers: ORE 550137 <br /> Serial numbers: FLE2100_R19-20343A <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP): 2555 Progress Way,Woodburn, OR. 97071 County: Marion <br /> Manufactured home park name, if applicable: <br /> ❑l 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): 427---Twi4igbt Ct. SE, Salem, OR. 07314. 91 3 I '7 County: Marion <br /> Manufactured home park name, if applicable: - 1 3 i 1-1/4A)1 I; i- <br /> ❑Oregon dealer lot Dealer name: <br /> Applicant signature: 7/1,a4_,_ (:)/(2„6,04.1..4.11 <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 /> ❑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 /> Ter <br /> BS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />