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, ''' Manufactured Home Trip Permit Application C.c LA `3 ;3 �`
<br /> ` 'i. Department of Consumer and Business Services
<br /> `max 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, ,
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<br /> ,..,.,...Sr.:. ..J,.:..l.,, �, ,: {,. .. ., .. . ,. , , APP��IGgIN�';INF,OR�fA�'�:N-:;. „ . .. .°i . , , ,.,:I 0':, .,i.
<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 /> Email:salesservIceoc@Jandmhomes.com
<br /> 'TRA►NSPORTER!INFORMATION ` . ..
<br /> Name:Same es above
<br /> Address (including city, state, and ZIP):
<br /> . Phone:
<br /> ' Email:
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<br /> l::
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<br /> .•z,•. .t;- :<" ;I:'<<. :`;'IHOME�INFOR AiTION� , .I: '•i;:
<br /> Home ID number(if known): DMV X-plate number(if known):
<br /> Manufacturer:Golden West . Model:Drm 483 F Years
<br /> ---HUD-label-numbersL--------------.. .. . _— - _.... .._.__...__... .—..— ---' i
<br /> Serial numbers:ALB0398680RAB
<br /> a!11;;' ,;:.'; t. IS .1*;„ : � � . 1i �. ?rry li}., :.tl;' ?L .,; :, .+ .� ., ,,;.,,..j
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<br /> Current location(including city,state,ZIP):15815 S Pope Ln Oregoncity, Or 97045 County: ,
<br /> Manufactured home park name,if applicable:
<br /> ❑Oregon dealer lot Dealer name:
<br /> 1 ❑'Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city, state,ZIP):22877 JennlemRd Lyons, Or 97358 County:Marlon I
<br /> .Manufactured home park name,if applicable:
<br /> ❑Oregon dealer lot a ler name:
<br /> Applicant signature: ..e._.k
<br /> Q�
<br /> Trip permit(per section $5,00(70511-1195), $
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<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 0 MasterCard 0 Discover Phone:( ) Department use only
<br /> $ •
<br /> • Cardholder signature Amount
<br /> Name of cardholder as shown on credit card •
<br /> Credit"card number Expiration
<br /> s'yt
<br /> s ' DCBS •
<br /> 1l, Business
<br /> 440-5225(10/17/COM) •
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