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6 a 3 5 5Lt_r 6 h'►n-e Wag S�� <br /> 610131 <br /> 5 ntrk <br /> � * Manufactured Home Trip Permit Application CO D 4 cam , <br /> Department of Consumer and Business Services <br /> vidiyBuilding 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 /> APPLICANTNFORMATION, . <br /> Name:J and M Hpmes, LLC <br /> Address (including city, state, and ZIP):15815 S Pope Ln Oregoncity 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:Golden West=Albany Model:ING 601K Year:2024 <br /> HUD label numbers:. <br /> Serial numbers:ALB043543ORABC <br /> ADDRESS INFORMATION <br /> Current location (including city, state,ZIP):2445 Pacific Blvd SW Albamy 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):6235 Sunshine Way SE Salem, Or 97317 County:Marion <br /> Manufactured home park name, if applicable: <br /> ❑ Oregon dealer lot Dg ler name: <br /> r`/ <br /> ' QJL(2 <br /> Applicant signature:; L� eA\ <br /> Amounti <br /> Trippermit(per section) $5.00(70511-1195) $ <br /> TOTAL 9' $ <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:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> ICBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />