MATT STEWART - EXP 12/2015 • OFFICIAL USE ONLY •
FORWARD TO P.D.
APPLICATION FOR TAXI OR LIMOSINE FOR HIRE OR RENEWAL
Please complete application to register with the City of Yelm.A renews/application shall be made in the same manner upon submittal of
the fee and other information and items required for the initial application,including photographs.(5.02.030 B)
Application Fee:$35.00 PAID PROOF REC'D-Waived if applicant has established an approved license from
another Thurston County city. Proof of the paid for-hire license for the same time period and background check must be shown
and verified.(5.02.070 C.)
Fingerprinting Fee$5.00 (5.02.030 A.1.)
•
Submit photographs with application- Three recent photos must be submitted with application.^(1x application,lx police
dept, 1 x attach to license when issued)
Driver's Name IV/ 4 <.L/ L 5 - (�.t f /C Phone number 3‘6 $ Y' of 63
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Driver's Address Q 01 Ye. et e (,-City,State and Zipcode 7 (' �
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to
Mailing Address /�CX / 2 6 l:ity,State and Zipcode Y `'^ t t/,� . ` 95/7
Valid Washington State Drivers License Number (5.02.030)
Vehicle License Tag/Plate Number (tk1.f],SJ
Proof of Ownership .
Birthdate /O - / — 3 Must be at least 18 years old.
Proof of Insurance
Business Name and Address K!!` City,State and Zipcode44,YK WPC Craill
Mailing Addr V• (6°, City,State and Zipcodek•S`CAYK-(kW 1.15141
Washington State UBI# 2. 433 (d $
1)Have you been convicted of a felony,or of operating a motor vehicle while under the influence of intoxicating liquor or drugs
or of being in actual physical control of a motor vehicle while under the influence of,intoxicating liquor or drugs,or of reckless
driving or negligent driving,or of vehicular homicide or vehicular assault,with five years preceding the date of application for
a license? Ai 0
2)Have you been convicted of three or more�moving violation during any one-year period within the five years preceding the
date of the application fora license? l
3)Are you at least 18 years with no physical or mental infirmity,which jeopardizes the ability to operate a for-hire vehicle.No
person shall drive a for-hire vehicle,including limousines,within the City without first obtaining a license therefore from the
City. Ve S
I certify my statements are true and accurate.My signature authorizes the City of Yelm to verify any information including a driver's
abstract.
Signature /�L ^\
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A�� CERTIFICATE OF LIABILITY '
INSURANCE DATE(MWOWYYYY)
PRODUCER (206)420-4270 FAX: (206)420-3284 7/7/2014
Key Insurance LLC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
5200 Sou thcenter Blvd, Ste 110 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tukwila WA 98188
INSURERS AFFORDING COVERAGE NAIL#
INSURER A:Gateway Insurance Company
Kelly Ray Foster, DBA: Kelly Kab
P.o. Box 1761 INSURER B:
INSURER C:
Yelm WA 98597
COVERAGES INSURERNSURER ED::
•r
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
'NY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MR*WV
LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTNE POLICY EXPIRATION
GENERAL LIABILITYDATE(MM/DD/YYYYI DATE lMM/DD/YYYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
•CLAIMS MADE f I OCCUR DAMAGE TO RENTEDPREMISES(Ea occurrent@) $
! ( MED EXP(Any one person) $
PERSONAL 8 ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
O-
1 POLICY 1----7 JF LOC _. PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT
A (Ea accident) $
ALL OWNED AUTOS 2AP625481401 7/16/2014 7/16/2015
X SCHEDULED AUTOS BODILY INJURY
(Per person) $ 100,000
HIRED AUTOS
BODILY INJURY
NON.OWNED AUTOS
(Per accident) $ 300,000
PROPERTY DAMAGE
$ 25,000
Per accldenl
GARAGE LIABILITY
ANY AUTO AUTO ONLY-EA ACCIDENT g
OTHER THAN EA ACC '$
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
OCCUR I J CLAIMS MADE EACH OCCURRENCE $
AGGREGATE $
DEDUCTIBLE $
•
RETENTION $ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY i WC STA'fU- 10TH-
AND
ANY PROPRIETOR/PARTNER/EXECUTIVE IY/i 1 TORY 1(MLTs I ER
OFFICER/MEMBER EXCLUDED9 E.L.EACH ACCIDENT
(Mandatory In NH) $
a yes,describe under E.L.DISEASE-EA EMPLOYEE $
'SPECIAL PROVISIONS below
I OTHER E.L.DISEASE-POLICY LIMIT $
CAP625481401 7/16/2014 7/16/2015 uim
im 25/50/10
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS •
2003 Mercury Sable 12FM50U83G626324
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
faxbls@dor.wa.gov
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30
DAYS WRITTEN
State of Washington NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Business Licensing Services
P.0 Box 9034 REPRESENTATIVES.
Olympia, WA 98034 AUTHORIZED REPRESENTATIVE
Steve Jones/MIA i e.
ACORD 25(2009/01)
INS025(200901).01 The ACORD name and logo are registered marks of ACORD RD CORPO N. All rights reserved.ACO
G. STATE OF WASHINGTON liii 111111111111 SERVICE
111111111 111111111 1111 111111
'
1E
Date: 09-17-2015
Application Id: 15 247 0336 UBI : 602 933 635 001 0002
Owner & Mailing Address: Business Location:
KELLY R FOSTER KELLY KAB
PO BOX 1761 222 E YELM AVE
YELM WA 98597 1761 YELM WA 98597 7662
---- REQUEST FOR PAYMENT
We cannot continue processing your Business License Application
until we receive the total amount of the required processing fees .
If we do not receive your payment by 10-02-2015, your application may
be rejected .
For Hire 110 . 00
For Hire Vehicle ( 1) 55 . 00
Business License Application Fee 19 . 00
Total Required Fees 184. 00
Amount Paid -74. 00
TOTAL AMOUNT DUE 110 . 00
Make checks payable to Deoartman+ of °-."----
q-23 360-62.64-/3e`r
40- twice<oje_-
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We cannot acce
Return this fo ci envelope .
Business Licensing SE ..__ Phone: (360) 705-6744 "---
PO
"�PO Box 9034 Fax: (360) 705-6699
Olympia WA 98507-9034 15 247 0336 FF=L21
For assistance or to request this document in an alternative format, visit http://business.wa.gov/BLS
or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718.
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