Laserfiche WebLink
1a. Dom`, , A .el <br /> e.,:;e.o. Manufactured Home Trip Permit Application <br /> `?` Department of Consumer and Business Services <br /> 1 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&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:bbaxter@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:bbaxter@jandmhomes.com <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:CMH Model:72DRM28483CH19 Year:2019 <br /> HUD label numbers: <br /> Serial numbers:ALB0387120RA,ALB038712ORB <br /> ADDRESS INFORMATION <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 /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):12413 Dominic Rd NE, Mt Angel, OR 97362 County:Marion <br /> Manufactured home park name, if applicable: <br /> ❑ Oregon dealer lot Dealer name: <br /> Applicant signature: ' £v n,9'Vl <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 0 MasterCard 0 Discover Phone:( ) Department use only <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> $$$DCBS <br /> Consumer and <br /> Business Services <br /> 440-5225(10/17/COM) <br />