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Aig15 Swe_ Rd IJE L5O cam, , to � <br /> -7i <br /> Manufactured Home Trip Permit Application <br /> ! <br /> .. '�'u``"z" " 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 /> APPLICANT INFORMATION <br /> Name:Amber Homes.LLC <br /> Address-(including city, state,and ZIP):221 Main St#2039, Lot Altos CA, 94023 <br /> Phone:.(210)692-4249 <br /> Email:inventory@amberhomes.us <br /> TRANSPORTER INFORMATION <br /> Name:Superior Home Transport LLC <br /> Address(including city,state, and ZIP):111 SOUTH SECOND STREETJEFFERSON, OR 97352 <br /> Phone:(541).327-7805 <br /> Email:ritahartzell@gmail.com <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Fleetwood Model:Weston Super Value Year2022 - <br /> HUD label numbers:ORE560105/06 <br /> Serial numbers:FLE210OR21-22870 A/B <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:Fleetwood <br /> El Out-of-state dealer lot Dealer name and contact information: <br /> -Placement location(including city, state,ZIP):4915 Swegle Road NE, Lot 58 Salem OR, 97301 County:Marion <br /> , Manufactured home park name, if applicable:Sunset Village <br /> ❑ Oregon dealer lot . Dealer n me: <br /> Applicant signature: ,% <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 /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> so,DCBS <br /> Consumer and <br /> Business Services <br /> 440-5225(I0/17/COM) <br />