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<br /> ' ,, Manufactured Home Trip Permit Application
<br /> s' 't ir.i. " Department of Consumer and Business Services
<br /> r� Building Codes Division S 4 $1 i 6
<br /> ri-.F
<br /> 1535 Edgewater St.NW,Salem,Oregon••Phone: 503-378-4530••Fax:503-378-4101 : - 1
<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 /> r ,Name:J and M Homes LLC
<br /> Address(including city,state,and ZIP):12901 Se 97th Ave Clackamas, Or 97015
<br /> Phone:.503-722,4.500,
<br /> Einail:salesserviceoc@Jandmhomes.com
<br /> TRANSPORTER INFORMATION
<br /> Name:Same as above - '1
<br /> Address(including city,state,and ZIP):
<br /> Phone:
<br /> Email:
<br /> ,
<br /> :HOME INFORMATION:; . : . :.. .:
<br /> Home ID number(if known): (J E DMV X-plate number(if known): _
<br /> Manufacturer:Golden West Model:DRM486F Year:-2023 --
<br /> HUD label numbers:
<br /> Serial numbers:ALB042417ORAB
<br /> ADDRESS INFORMATION
<br /> Current location(including city,state,ZIP):2445 S Pacific Blvd Albany, Or 97321 County:Linn i.
<br /> Manufactured home park name,if applicable: 1
<br /> _p_Oregon dealer lot Dealer name: i
<br /> 'Out-of-state dealer lot Dealer name and contact information:
<br /> . Placement location(including city,state,ZIP):11667 Grouse Lane NE Aurora,Orr 97002 County:MAM .. ,
<br /> Manufactured home park name,if applicable:
<br /> ❑Oregon dealer lot Dealier name: j
<br /> Applicant signature: �/ ���ii (&Q �1 c,
<br /> j3
<br /> SIArhgUn is
<br /> Trip permit(per section) $5 00(70511 1195) $
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<br /> �..yy. rii#�Y t > O r .�. .�.�?_-. tM, K �C f`. T,0T*,u. $
<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 /> `' ' CBS
<br /> • Conmmerand
<br /> BustnessServkes
<br /> 440-5225(10/17/COM) I
<br /> 1
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