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ao3 -1 Car i s 5 ANI-e_ NE1 f(..9,--votr9 (00 '734Ll <br /> '�?"'''' Manufactured Home 'Trip Permit Application <br /> �'"`r' Department of Consumer and Business Services 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 /> '^ APPLICANT INFORMATION` <br /> Name:J and M Homes, LLC <br /> Address(including city, state, and ZIP):15850 S Pope Ln Oregon City Or 97045 <br /> Phone:503-908-8967 <br /> Email:salesserviceoc@jandmhomes.com <br /> TRANSPORTER 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-Cmh Manufacturing Model:ING661 M Year:2023 <br /> HUD label numbers: <br /> Serial numbers:ALB0427300RA <br /> '„ ADDRESS INFORMATION �'= <br /> Current location(including city, state,ZIP):2445 Pacific Blvd Albany Or 97321 County:Linn <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,ZIP):22037 Carissa Ave NE Aurora, Or 97002 County:Marion <br /> .Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dea er name: <br /> Applicant signature, j Oi/( Q�( p - ,0�J <br /> Amount <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> ;.k . 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 0 MasterCard 0 Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> i <br /> Credit card number Expiration <br /> ( DCBS <br /> Consumer and . <br /> Business Services <br /> 1 440-5225(10/17/COM) <br />