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<br /> Manufactured Home Trip Permit Application
<br /> Department of Consumer and Business Services ni 3 5 7.0 a-O
<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 of certification.y
<br /> �� ti v ,f0akrOA 1 ,NFOJ M'A1TO AVATI C
<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@andmhomes com
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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@jandmhomes.com
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<br /> Home ID number(if known): DMV X-plate number(if known):
<br /> Manufacturer:CMH Model:72DRM28483CH18 Year:2018
<br /> HUD label numbers:
<br /> Serial numbers•ALB0383580RA ALB0383580RB {mss �� r g} „
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<br /> Current location(including city,state,ZIP):2445 Pacific Blvd SW,Albany, OR 97321 County:Linn
<br /> Manufactured home park name,if applicable:
<br /> ❑Oregon dealer lot Dealer name:
<br /> 0 Out-of-state dealer lot Dealer name and contact information:
<br /> Placement location(including city, state,ZIP):9801 Jordan St SE,Aumsville, OR 97325 County:Marion
<br /> Manufactured home park name, if applicable:
<br /> ❑Oregon dealer lot Dealer name:
<br /> Applicant signature: eRGIL
<br /> Trip permit(per section) $5.00(70511-1195) $
<br /> h . �a . ' a> a:;* A a $
<br /> '�°"', ,,t„.�:e���"�'�✓<�s��:�= .Rs.a,t-s?..�. _.tom..r asT♦�xl�r7.z
<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 ❑]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 /> •
<br /> CBS
<br /> Camumerand
<br /> Suness Services'
<br /> 440-5225(10/17/COM)
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