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M55 fCb <br /> Manufactured Home 'Tri Permit Application <br /> P PP <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 m 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 /> v , A dr 3 `�� ,' APPLICANT II I ORMAT-0147:,,. a,.., . f .> , r,xS ,;, ;-�° ;�, <br /> .,. ., .. <br /> Name:J&M Homes LLC <br /> Address(including city, state,and ZIP):12901 SE 97th Ave, Suite 100, Clackamas, OR 97015 <br /> Phone:503-908-8166 <br /> Email:apowell@jandmhomes.com <br /> TRANSPORTER INFORMATION r k <br /> Name:J&M Homes LLC <br /> Address(including city, state,and ZIP):12901 SE 97th Ave, Suite 100, Clackamas, OR 97015 <br /> Phone:503-908-8166 <br /> Email:apowell@jandmhomes.com <br /> HOME } <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:CMH Model:72ING28523AH 18 Year:2018 <br /> HUD label numbers: <br /> Serial numbers ALB0378440RA ALB0378440RB <br /> j h iDDRESS,:INFORMATION r <br /> Current location (including city, state, ZIP):2445 Pacific Blvd SW, Albany, 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):6267 Brentwood DR SE, Salem, OR 97306 County:Marion <br /> Manufactured home park name, if applicable: <br /> ❑ Oregon dealer lot Dealer name: • <br /> Applicant signature: brgel 094-.7 <br /> Amount: <br /> Trip permit(per section) S5.00(70511-1195) S <br /> • t - - TOTAL ', S <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 /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> • r <br /> Credit card number Expiration <br /> Consumer and <br /> Business Services <br /> 1 440-5225(10/17/COM) <br />