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D NI , Ma; n 3 <br /> o'ar''� Manufactured Home Trip Permit Application <br /> 4- . 6 8 ryil.A nc./. ) <br /> 0,:y Department of Consumer and Business Services <br /> X 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 /> . . � a . . APPLICANT'INFORMATION - ,; <br /> : <br /> • Name:J and M Homes, 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:Marlette-Hermiston Model:Majestic 9601-S Year:2024 <br /> HUD label numbers: <br /> Serial numbers:HERO34391ORAB <br /> '` : `' D DRESS;INFORMATION r , '''' , , , :. <br /> Current location(including city, state, ZIP): `/ Q( (. E Ikue # 1 <br /> rP c\ /- k County:Umatilfa <br /> Manufactured home park name, if applicable: <br /> 1 ❑Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):830 North Main Spc 68 Mt Angel Or 97362 County:111/1 Ctmy—v cV\,.. <br /> Manufactured home park name, if applicable:Bavarian Village Mobile Park <br /> ❑ Oregon dealer lot D9 ler name: /� <br /> Applicant signature 74 (,,,,.(� cd1 <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 /> II CBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />