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`k #A, manufactured Home Trip Permit Application La O(0 5 3 q <br /> ' '`17, Ai i Department of Consumer.and Business Services <br /> 114 <br /> to Building Codes Division <br /> 1535 Edgewater St,NW, Salem,Oregon•Phone: 503-378-4530 •Fax:503-378-4101 <br /> Web: oregon.gov/bcd•Eniail: 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 /> - , APPLICANtINFORMATION <br /> Name:J& M Homes, LLC <br /> Address(including city, state,and ZIP):12901 Se 97th Ave#100 Clackamas, Or 97015 <br /> Phone:503-722-4500 <br /> ' Emalsalesserviceoc@jandmhomes.com <br /> :i ANSPORTER INFORMATION , <br /> Name:Same as above <br /> Address(including city, state,and'ZIP): <br /> . Phone: <br />- : Email: <br /> HOME'INFORMATION;.._. ;., <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Golden West Model:Drm 483 F YearQ() <br /> -HUD-label-number-s: --- ----..-..... _... - ..-__ _ ------------... .-----..._._...---------- ---------� <br /> Serial numbers:ALB0398680RAB • <br /> F ADDRESS INFORMATION <br /> • Current location(including city, state,ZIP):15815 S Pope Ln Oregonclty, Or 97045 County: <br /> Manufactured home park name,if applicable:0 Oregon dealer lot Dealer name: <br /> ' '❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):22877 JenniemRd Lyons, Or 97358 _ County:Marion <br /> •Manufactured home park name,if applicable: <br /> ❑'Oregon dealer lot De ler name: <br /> Applicant signaturr\a.A..e...K.e.„-- 1-?(2_,!)..,c_k <br /> - :Amount:';,a. <br /> Trip permit(per section) $5.00(70511-1195){{ � $ <br /> 1. i i. !;:,' '�.1?' i _.'+.. S'P .� _ .._:?a'-L.,!.�•,�4 s':`"l.,Q I A i'''R- $ <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 /> / <br /> Credit.card number Expiration <br /> {f <br /> Yn:rti <br /> D* CBS . <br /> ''r Consumer and <br /> Business Services <br /> 440-5225(10/17/C0M)• <br />