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c , 1 . <br />, . : .- : . b LcunCaS-1-tv 0 r M E 44'3..-)N, ct 1, [iy.)- - ' 1 ' <br /> 'v •:, : .Manufactured Home Trip Permit Application <br /> Vt.4'y Department of Consumer and Business Services (///// /� £3• Building Codes Division <br /> r. <br /> 1535 Edgewater St.NW, Salem, Oregon •Phone; 503-378-4530 • Fax: 503-378-4101 • . <br /> Web: oregon;gov/bcd • Email: inhods.bcdC,oregon,gov , <br /> This application must be.submitted with a valid tax certification from the county in which the home is currently'located,._..__:_: <br /> and <br /> as well as the county the home is moving to. A valid tax certification is one that has been certified by the county = : - <br /> `submitted before the expiration date provided by the county at the time of certification. <br /> .Y �" t: r:.AI RL,IGANT.INFO,RMAT[ON.. - <br /> `\..Y \ .11( t S utt! ,y ill ST] - .., .:. !�, .1 <br /> i 3 <br /> Nolte:Stephen P Crook <br /> Address(including city,state, and ZIP):2151 Three Lakes Rd. SE.#1 Albany, Oregon 97322 <br /> Phone:541-337-4197 <br /> Email:parksidemhc1@comcast.net :_ <br /> .j TRANSP.ORTER.INF.O.RMATION-°�-'•-`:; <br /> Name:Bennett Truck Transport <br /> Address (including city, state, and ZIP):1360 Industrial Ave. Woodburn, Oregon 97071 <br /> Ph`onc:503-981-7939 - <br /> Email nancys wbo@bennett(g com <br /> - 'HOME:INF'ORMATION; <br /> , <br /> Home ID number(if known): I DMV X-plate number(if known): <br /> Manufacturer:Fleetwood I Model:Sandpointe Year:2022 <br /> HUD•label nuMbers:ORE 560023 <br /> Set iaf number s FLE2100R22 22810A <br /> :,..ADDRESS-INFORMATION , . <br /> Current location (including city, state, ZIP):1360 Industrial Ave.Woodburn, Oregon 97071 County:Marion___ <br /> Manufactured home park name, if applicable: <br /> ❑ Oregon dealer lot I Dealer name: <br /> Out-of-state dealer lot I Dealer name and contact information: <br /> Placement location(including city, state,ZIP):4882 Lancaster Drive NE.#22 Salem, Oregon 97305 County:Marion <br /> Manufactured home park name, if applicable:Starlite MHC LLC <br /> ❑ Oregon dealer lot I Dealer name: <br /> Applicant;signature: ,,, p <br /> Amount .• <br /> • <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> Y: <br /> t- 4 t.r � � rut)- ^.L R ti ie1 ,1:: S <br /> , '`.a:�;�r.i.}.•- �. _:�)', :,,�;. .. t :_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 /> i <br /> Credit card number Expiration <br /> ;DCBS <br /> "' tmuumerand <br /> Business Senior <br /> ' 440-5225(10i17/COM) <br />