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Manufactured Home Trip Permit Application 1 <br /> r <br /> W V Department of Consumer and Business Services 3 5 id' 1 <br /> • Building Codes Division <br /> ti- <br /> 1535 Edgewater St.NW, Salem,Oregon •Phone: 503-378-4530 • Fax: 503-378-4101 , <br /> a <br /> Web: oregon.gov/bed • Email: mhods.bcd oregon.gov . 39 79 ac <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 /> . APPLICANTNFORMATION <br /> Name:CPI SUNDIAL OWNER LLC <br /> Address(including city, state,and ZIP):2020 Maltby Rd, Suite#7, PMB#109, BOTHELL, WA 98021 <br /> Phone:503-363-6234 <br /> Email:SUNDIAL@ FC P N W.CO M <br /> TRANSPORTER INFORMATION <br /> Name:ROGERS HEAVY HAUL LLC <br /> Address(including city,state,and ZIP):12121 HILLCREST DR SE, YELM,WA 98587 <br /> Phone:360-507-7015 <br /> Email:YELMHAULING@GMAIL.COM • <br /> HOME INFORMATION <br /> Home ID number(if known):New Home DMV X-plate number(if known): <br /> Manufacturer:MARLETTE Model:55CRC20422AH20 Year:2020 <br /> HUD label numbers:ORE550888;°ORE550887 <br /> Serial numbers:u E 03 959OR AIB <br /> H R 1 <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP):400 W ELM AVE, HERMISTON, OR 97838 County:Umatilla <br /> Manufactured home park name,if.applicable: <br /> Oregon dealer lot Dealer narne:MARLETTE HOMES (Factory-new home) <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):2200 Lancaster Dr. SE,#11D, Salem, OR 97317 County:Marion <br /> Manufactured home park name, if applicable:S ndial Mobile Home Park <br /> ❑Oregon dealer lot D-.ler ..., -:\ <br /> Applicant signature: ` '41 1 I 3, sot, ,Tara Rivinius, Agent for Owner <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $10.00 <br /> • TOTAL: $10.00 <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:1503) 363-6234 Department use only <br /> $10.00 <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> 06 /2023 <br /> Credit card number Expiration <br /> SIP C BS <br /> Consumer and S cannt <br /> Business Services <br /> 440-5225(10/17/COM) <br />