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roadorAv c( 54 <br /> Manufactured Home Trip Permit Application lZaia/ .e *I <br /> N i 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@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&M Homes, LLC , <br /> Address(including city,state,and ZIP):15850 S. Pope Lane <br /> Phone:503-908-8166 <br /> Email:aspencer@jandmhomes.com <br /> TRANSPORTER INFORMATION <br /> Name:J&M Homes - <br /> Address(including city, state,and ZIP): <br /> Phone:503-908-8166 <br /> Email:aspencer@jandmhomes.com <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:CMH MFG,West Hermiston Model:Tempo-Under Pressure Year:2024 <br /> HUD label numbers:NTA2236684, NTA2236685 <br /> Serial numbers:HER0341440RA, HER034144ORA <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP):400 W. Elm Ave. County:Hermiston <br /> Manufactured home park name, if applicable: <br /> El Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):133B Broadmore Ave. Salem, Or 97301 County:Marion <br /> Manufactured home park name, if applicable:Royal Estates <br /> ❑Oregon dealer lot eater name: <br /> Applicant signature: V5P(Al << Amount <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> 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 ❑MasterCard El Discover Phone:( ) Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> DCBS <br /> i Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />