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4ThoAubuyn Rd NiE, IOC .SctIe <br /> Manufactured Home Trip Permit Application <br /> Department of Consumer and Business Services <br /> ' • Building Codes Division <br /> • <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 dateprovided bythe countyat the time <br /> 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/atoit'n): DMV X-plate number(if known): <br /> Manufacturer:Marlette Model:Tempo Series Year:2024 - <br /> HUD label numbers: <br /> Serial numbers:HER034077ORAB <br /> ADDRESS=INFORMATION <br /> Current location(including city, state, ZIP):33213 Highway 34 SE Albany, Or 97322 County:Linn <br /> Manufactured home park name, if applicable: <br /> ❑ Oregon dealer lot Dealer name: <br /> El Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state, ZIP):4730 Auburn Rd NE 103 Salem Or 97301 County:Marion <br /> Manufactured home park'iiame, if applicable: <br /> ❑ Oregon dealer lot ealer name: <br /> Applicant signature'104,e 14 e 6,0,e1/\ <br /> Amount w,, <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 /> El Visa ❑MasterCard El Discover Phone:( ) <br /> Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> $ft DCBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />