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.. <br /> , . •, ) 6 (9 'B 8 )1 .0 I--)w a ci 9 E .1 .,) L - 3 6 . <br /> . AP . <br /> . -- Manufactured Home Trip Permit Application <br /> .'•: , i Department of Consumer and Business Services <br /> Building Codes Division 60 78 i ci <br /> 1535 Edgewater St. NW, Salem, Oregon•Phone: 503-378-4530 •Fax: 503-378-4101 <br /> Web: oregon.gov/bcd o Email: mhods.bcd@oregon.gov . <br /> • <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 /> . Nanie:J and M Homes, LLC <br /> Address(including city, state, and ZIP):15815 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 /> _ <br /> Address (including city, state, and ZIP): <br /> Phone: <br /> Email: ' <br /> HOME INFORMATION <br /> Home ID number(if knoii'n): DMV X-plate number(if known): . <br /> Manufacturer: CCA .tT�, -� \--- —A4hC4.v-Us.) Mode1:72TEM16552AH24 Year:2024 <br /> ,HUD label numbers: <br /> •Serial numbers:ALB043498ORA <br /> ADDRESS INFORMATION <br /> Current location (including city, state,ZIP):2445 Pacific Blvd SW Albant, Or 97321 County:Linn <br /> Manufactured home park name, if applicable: <br /> ❑.Oregon dealer lot Dealer name: <br /> ❑ Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):16688 HWY 99E SPC#30 Woodburn, Or 97071 County:Marion <br /> Manufactured home park name, if applicable: �' a�e_�As.,L V l \,c, ;; e - <br /> (II Oregon dealer lot Dea r name: <br /> J <br /> Applicant signature: c,�-- ''� �/L_C�,�/1.. ,, 1:1).12/).__,C,,e-}// <br /> ,: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 ❑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 /> 3CBS <br /> Consumer and • <br /> Business Services <br /> 440-5225(l0/17/COM) <br />