|
5 (oOMOr3cAi NE , 5rt,,C�
<br /> Oct Prop vet e�
<br /> ,
<br /> e
<br /> Manufactured Home Trip Permit Application m 3 5-)o., "3
<br /> 7; 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 • Email: mhods.bcd@aoregon.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��oyf certification.
<br /> r>. 1`.. `''. 'S .�ii'�°"�Ft`i�.� ,fit r;ax i >''-5� r a v OxM Aragga5t`i.a��
<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 IN ORMA`i ION rT t t F S3�3
<br /> t f ttit. ».r.,'-".i,..
<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 /> iiomrr " .tam,'* a ,h' yGaMa , IHOMEINFORMATI,ON . .ft.i., .,n. 4 M_.f *.seko,: .:'
<br /> Home ID number(if known): I DMV X-plate number(if known):
<br /> Manufacturer:CMH I Model:72DRM14522AH18 I Year:2018
<br /> HUD label numbers:
<br /> Serial numbers ALB0383120R
<br /> c :r 5 -e � {VtAT�QN� !!`ti r�tw`✓ra ?�x,u r'gL f�,`�ry�"y �[ '�':Nlt .+-�''p'��5+,� � ���C
<br /> a, k ADORES R + M r� r 4 .:P. � .x,.
<br /> S INFO .�._.�.� ..
<br /> � �',c? " !`��u*u t?.r. .ts}zE"�v:.rx� � s �...tai a=.� a ..,.: .ar .,..z'-.;5; ,,�28�'^ � <�,
<br /> Current location(including city,state,ZIP):2445 Pacific Blvd SW,Albany, OR 97321 I 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):560 Morgan Ave NE, Salem, OR 97301 I County:Marion
<br /> Manufactured home park name, if applicable:
<br /> Cl Oregon dealer lot Dealer name:
<br /> Applicant signature: ,
<br /> Trip permit(,er section) �}$5 00(70511-1195)y $
<br /> "yyww'.c'ar� .o.'�,�aVit `.' #?.... ,v14110.401( , $
<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 /> Credit card number Expiration
<br /> CBS
<br /> Consumer and
<br /> Business Services
<br /> 440-5225(10/17/COM)
<br />
|