Laserfiche WebLink
1i (o5 -7 Grov,st Lri NE, Aoret, <br /> ' `N Manufactured Home Trip Permit Application 3 13 <br /> •144, <br /> ,;f -�'�- Department of Consumer and Business Services <br /> r 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 /> APPLICANT INFORMATION_ - - <br /> Name:J and M Homes LLC <br /> Address(including city, state, and ZIP):15815 S Pope Ln Oregon City Or 97045 <br /> Phone:503-890-8967 <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(f known): <br /> Manufacturer:Marlette Hermiston <br /> miston Mode1:55TMP28483AH25 Year:2025 <br /> HUD label numbers: <br /> Serial numbers:HER034571 GRAB <br /> ADDRESS INFORMATION <br /> Current location(including city, state, ZIP):400 W Elm Ave Hermiston, Or 97838 County:Umatilla <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: Ac.&, 5441g9 <br /> Placement location(including city, state,ZIP):11657 Grouse Lane NE Aurora, Or 97002 County:Marion <br /> Manufactured home park name, if applicable: <br /> 0 Oregon dealer lot D ,ler name: <br /> Applicant signat � r"�` 1 <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 /> vtiDCBS • <br /> Consumer and <br /> Business Serukes <br /> 440-5225(10/17/COM) <br />