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Mt 1ls�r, 1�evk <br /> `7410 5 +h <br /> X , Manufactured Home Trip Permit Application rYI 3 5 (0 4 o <br /> Ira 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 /> e before the expiration date provided by the county at the time of certification. <br /> submitted <br /> sub p <br /> . +aE°le��i4.�y:r- t4 -'kLY" a `'Yt�.�5.SZAP l"iASINTPORNIV , MY,. .':''.i zC3.. r....w r <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@jandmhomescom <br /> ,, ,: , } n' F OVT. ...,OSIORTER'f .,_.. _....TI� .�.rt . ;{ `". r�,._ .. f�� ... <br /> RAMS _ � , NFORMA N ` °� � " ��` <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 /> _3, t" _ .y,T ri r `; "'.:E-1 MoN .rs.._. rMATi N ";. .....nss ag...!"+zM,._aolstro <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:CMH Model:72DRM28443BH 18 Year:2018 <br /> HUD label numbers: <br /> Serial numbers:ALB038304ORA ALB038304ORB <br /> l € MI�x r ` ADDRESS'INFORMATION , Ss s ,$.tst ..R W. ii ,Wht,;;r <br /> Current location(including city,state,ZIP):2445 Pacific Blvd SW,Albany, OR 97321 County:Linn <br /> Manufactured homeark name, if applicable: <br /> CIOregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):7410 5th St SE,Turner, OR 97392 County:Marion <br /> Manufactured home park name, if applicable: <br /> ❑Oregon dealer lot Dealer nam����)'''7 <br /> Applicant signature: <br /> Wektanal <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> Ea-WPMF ;, ";<rfi wMO*, -O ' L'R $ <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 /> tom_ t <br /> CBS <br /> cansvmerand <br /> Busicuss Services <br /> 440-5225(10/17/COM) <br />