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AGI `7 5 + 1 v. K)E , setlev,, 9.--705 <br /> .* Manufactured Home Trip Permit Application 4,b g 4 <br /> t;'• ' 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 ce 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-platc number(if known): <br /> Manufacturer:CMH mFG-Hermiston- Marlette Modc1:55MSP28603AH20 Year:2019 <br /> HUD label numbers: <br /> Serial numbers:HER031767ORAB <br /> ,a . ;` ADDRESS INFORMATION <br /> Current location(including city, state, ZIP): 15815 S Pope Ln Oregon City, Or 97045 County:Clackamas <br /> Manufactured home park name, if applicable: <br /> 0 Oregon dealer lot Dealer name: <br /> 0 Out-of-state dealer lot Dealer name and contact information: <br /> _Placement location(including city, state,ZIP):8491 75th Ave Ne Salem , Or 97305 County:Marion <br /> Manufactured home park name, if applicable: <br /> 0 Oregon dealer lot D a er name: <br /> Applicant signature: � �-1 cytt,p-t, ____,A? ' N <br /> Amount <br /> Trip permit(per section) $5.00(70511-1195) $ <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 /> Credit card number Expiration <br /> ,#DCBS . <br /> 4 Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />