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BA Q 1 .._7 5 +h v->a K)E r ss a, 1.evY, 9-3 0 5 <br /> Manufactured Home Trip Permit Application too 8 54 5 <br /> ` p ; = Department of Consumer and Business Services <br /> •' Building Codes Division <br /> t. • <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 /> zx .:.. ,v: ' TRANSPORTER;;,:INFORMATION <br /> ' 'Name:Same as above. <br /> .Address (including city,state, and ZIP): <br /> Phone: <br /> Email: <br /> k :.HOME INFORMATION. <br /> Home ID number(if known): DMV X-platc number(if known): . <br /> Manufacturer:CMH mFG-Hermiston- Marlette Mode1:55MSP28603AH20 Year:2019 <br /> HUD label numbers: <br /> :Serial numbers:HER0317670RAB <br /> '''' ., '', 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 /> ❑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:.,,). " r.Z/( eir l_ Q ,-(e-97-4-e—CN <br /> :Amount: <br /> s <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> s' r .'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 /> 0 Visa ❑MasterCard ❑Discover Phone:( ) <br /> 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 /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) , <br />