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<br /> ' Manufactured Home Trip Permit Application
<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 • 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@landmhomes com
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<br /> Nr . i r', r itANSPORTER INFORMATION : O...,k 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@landmhomes com
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<br /> Home ID number(if known): DMV X-plate number(if known):
<br /> Manufacturer:CMH Model:55MAJ40644AH17 Year:2017
<br /> HUD label numbers:ORE 533609, ORE 533610&ORE 533611
<br /> Serial numbers:HER030394ORA HER030394ORB&HER030394ORC
<br /> A M t hr r F , 'ADDRESS INFORMATION 3 s. . ,Vl ,Zn :, t. eZ,,._....,
<br /> Current location(including city, state,ZIP):33213 Hwy 34 SE,Albany, OR 97322 County:Linn
<br /> Manufactured home park name, if applicable:
<br /> El 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:
<br /> D Oregon dealer lot • Dealer name:
<br /> Applicant signature: (*MAL ,i .!mye4'7
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<br /> Trip permit(per section ,$5.00(70511-1195) $
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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 /> 0 Visa 0 MasterCard D Discover Phone:( ) Department use only
<br /> Cardholder signature Amount
<br /> Name of cardholder as shown on credit card
<br /> Credit card number Expiration
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<br /> 6nineisServices •
<br /> 440-5225(10/17/COM)
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