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<br /> -114, Manufactured Home Trip Permit Application
<br /> ,,,,,,-.13.0„,, Department of Consumer and Business Services
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<br /> 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.
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<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@jandmhames.com
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<br /> Name:J&M Homes LLC I
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<br /> Address(including city,state, and ZIP):12901 SE 97th Ave,Suite 100, Clackamas, OR 97015 I
<br /> Phone:503-908-8166 •
<br /> Email:apowell@jandmhomes.com �,,, �:y�.,.�2 �: .A:,;;
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<br /> Home ID number(f known): DMV X-plate number(if known): I
<br /> Manufacturer:CMH Model:55MAJ40644AH17 Year:2017
<br /> HUD label numbers:ORE 533609, ORE 533610 &ORE 533611
<br /> Serial numbers:HER0303940RA, HER030394ORB&HER030394ORC . ' I
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<br /> Current location(including city,state,ZIP):33213 Hwy 34 SE,Albany, OR 97322 County:Linn
<br /> Manufactured home park name, if applicable: M
<br /> ©Oregon dealer lot Dealer name:J&M Homes
<br /> D Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city,state,ZIP):33503 Railroad Ave, Gates, OR 97346 , County:Marion
<br /> Manufactured home park name, if applicable: I
<br /> 4
<br /> ❑Oregon dealer lot• Dealer name: •
<br /> Applicant signature: (*tI, )8:01,40j47
<br /> Trip ermit 1per section $5.00(7)511-1195 $
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<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 0 MasterCard 0 Discover Phone:( ) Department use only -
<br /> .
<br /> $
<br /> Cardholder signature Amount
<br /> • I
<br /> Name of cardholder as shown on credit card
<br /> i
<br /> Credit card number .Expiration
<br /> „„-10 CBS
<br /> • .Canurnaiid
<br /> Business 5w ke$
<br /> 440-5225(10/19/COM) •
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