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. \ 2 Woodlancl Ln '--- m 3 5-70 a7 <br /> 40-:,.,,,,7-',,,,-k-'6, Manufactured Home Trip Permit Application <br /> :',mt.. <br /> *44r.:.� Department of Consumer and Business Services <br /> `''``"_ BuildingCodes Division <br /> i. 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 /> PLICANT.INFORMATION : ;,< :. , <. .,. : ...,. <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 INFORMATION <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 /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:CMH Model:72DRM28443BH19 Year:2019 <br /> HUD label numbers:ORE 545132, ORE 545133 <br /> Serial numbers:ALB0384530RA,ALB0384530RB <br /> ADDRESS INFORMATION <br /> Current location(including city,state,ZIP):33213 Hwy 34 SE,Albany, OR 97322 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):13262 Woodland Ln, SE,Turner, OR 97392 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dea er name: . <br /> Applicant signature: c47 "641 ,941 <br /> � yl <br /> Amount <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> .. ....:.. . .. <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 0 MasterCard 0 Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> • <br /> $ittDCBS <br /> Censumerand <br /> Business Services • <br /> 440-5225(10/17/COM) <br />