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D-3 5-0 6 A i it v o r Rd' iv'E .A uyo ir-9._ tt iv b g701 <br /> 047‘ <br /> Manufactured Home Trip Permit Application <br /> 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 and M Homes. LLC • <br /> Address (including city,'state, and ZIP):159850 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:Cmh Golden West Albany Model:DRM 682F Year:2024 <br /> HUD label numbers: <br /> Serial numbers:ALB042418ORAB <br /> _ r. ADDRESS INFORMATION . <br /> Current location (including city, state,ZIP):2445 S Pacific Blvd County:Linn <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):22506 Wport Rd NE Aurora. Or 97002 County:ihrW1,03r' <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot . aler name: <br /> Applicant signature: / () e <br /> ____ r-034-0-41 <br /> Amount <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> . " TOTAL`'1" $ <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 ❑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 Senices <br /> 440-5225(I0/17/COA4) <br />