Laserfiche WebLink
915 5uje1eKdJL7cJ'9` <br /> ) Manufactured Home Trip Permit Application ( �J 5 E3B Se/. <br /> FI .. . <br /> . ;. , 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 /> . <br /> APPLICANT INFORMATION _' <br /> Name:Amber Homes LLC <br /> Address (including city, state, and ZIP):221 Main St.#2039 Los Altos, CA, 94023 <br /> Phone:253-221-1757 <br /> Email:clare@annberhomes.us <br /> TRANSPORTER4INFORMATION ': _ <br /> Name:Westspan Hauling <br /> Address (including city, state, and ZIP):Hermiston, OR <br /> --- <br /> - <br /> Phone: - - <br /> Email: <br /> HOME INFORMATION - . :_t ; <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Marlette Model:Columbia River Year:2020 <br /> HUD label numbers: <br /> Serial numbers:HER031894ORA/B <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 /> ❑p Oregon dealer lot Dealer name:Marlette <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):4915 Swegle Road NE 79, Salem OR 97301 County:Marion <br /> Manufactured home park name, if applicable:Sunset Village <br /> EIOregon dealer lot ealer name: <br /> Applicant signature:( •,Q, j,t,44,�, <br /> )70mount:` <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 /> 0 Visa 0 MasterCard 0 Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> i <br /> Name of cardholder as shown on credit card <br /> / I <br /> Credit card number Expiration <br /> fDCBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />