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t BU )�� 1ZCIi J <br /> :, Manufactured Home Trip Permit Application <br /> Department of Consumer and Business Services <br /> a • .Building Codes Division <br /> 1535 Edgewater St. NW, Salem,Oregon'Phone: 503-378-4530 • Fax:503-378-4I01 <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 /> us 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 /> .. .. .,.,„ . ...��w r ,., .•: . .. �h t a ., . Af�P CAIUT�;INFORM�4TI.ON x '� £� � x � �x ' 4� <br /> Name:SUPERIOR HOME TRANSPORT, LLC <br /> Address(including city,state,and ZIP):PO BOX 1067, JEFFERSON, OR 97352 <br /> Phone:541-327-7805 <br /> Email:RITAHARTZELL@GMAIL.COM <br /> fir; TRA►NSPO,RTER INFORMATION <br /> Name:SUPERIORHOME TRANSPORT, LLC <br /> Address(including city,state,and Z[P):PO BOX 1067, JEFFERSON, OR 97352 <br /> Phone:541-327-7805 .. <br /> Email:RITAHARTZELL@GMAIL.COM <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:FLEETWOOD HOMES Model: Year:2023 <br /> HUD label numbers: <br /> Serial numbers:FLE2100R23-23397A <br /> ',..s °,} xA tt y . ' 3 „'ADDRESS.;INFORMATIO�I : <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,ZLP):5355 RIVER RD N#80, KEIZER, OR 97303 County:MARION <br /> Manufactured home park name, if applicable:MCNARY OAKS <br /> ❑Oregon dealer lot Dealer.name: <br /> Applicant signature: , -' <br /> fiAi1[I�G nt`' <br /> Trip permit(per section) $5.00(70511-1195) S <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 /> I'CBS <br /> (asumcraa, <br /> Business services <br /> 440-5225(lO/17/COM) <br />