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KELLY FOSTER - EXP 12/2015r--T-:-. : .:. • V f OFFICIAL USE ONLY FORWARD TO P.O. APPLICATION FOR TAXI OR LIMOSINE FOR HIRE OR RENEWAL Please complete application to register with the City of Yelm.A renewa/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. (lx application,lx police dept, lx attach to license when issued) Driver's Name h,`e,� jgA-C Phone number 3tP0 \ -`q, Driver's Address.��\\ <42.50—i G City,State and Zipcode Mailing Addres CI&\ City State and Zipcode L2Vit.lin CV cat6z Valid Washington State Drivers License Number (5.02.030) Vehicle License Tag/Plate Number PtE es \ti,,,t-3— Proof of Ownership Birthdate 31 2 ki/ I'1449 Must be at least 18 years old. il Proof of Insurance Business Name and Address V---P\`►.k City,State and Zipcode\*q'G.lVN We( (i 85-q7 Mailing Address \7 (it City,State and Zipcode e.,\Wl k rOM" Q Washington State OBI# 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? 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 for a license? NO 3)Are you at least 18 years with no physical or mental infirmity,which jeopardizes the ability to operate a for-hire vehicle.lJo person shall drive a for-hire vehicle,including limousines,within the City without first obtaining a license therefore from the City. I certify my st�: .• Ind accurate.My signature authorizes the City of Yelm to verify any information including a driver's abstract. Signature r vt' Date I� ) / (,,,� m ` �� AEB1445 !06/2011 T301684 I 06/20/20151 21460 2003 12 ; , G CAB 2003 1 MERG SAB4D '< Vehicle!dent(VIN)/Serial no Reg col Scale wt Seats Model' ST Owl Ow st Owl exa Piet Equip 1MEFM50U83G626324 27 3202 SG 4D .__..__...._:._..._ Prey plate Firing TED RTA Tax ! Subagent GwtNeh wt Other f Total.fees Owl c. 011SET $3.00 I $5.00 $10.00 $30.75 $48.75 ` = FOSTER,KELLY RAY DBA "T - KELLY KAB ; ' PU BOX 1761 YELM WA 98597 E,� h r s ,r , ,11 L " X )1.___ ... _...:: ....._ -- ..............._............ Signature of registered owner(sl Signature ut iegistered owner(s) Comments: COLOR-GREEN-DISPLAY TAB ON BACK LICENSE PLATE ONLY-FRONT PLATE IS STILL REQUIRED. E Validation code 01342204141720621140007040761 1111111.,ii,'..14.7 4RThis certificate is not proof of ownership. s PT ID: AREGPR-1 ' ,fir, .: s. I a AJ� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) PRooucER (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 SouLhcenter 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 NAIC# INSURER A:Gateway Insurance Company Kelly Ray Foster, DBA: Kelly Kab P-o. Box 1761 INSURER B: INSURER C: Yells WA 98597 COVERAGES INSURERINSURER ED:: ThoE POL;CiES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY 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. i6F"� • a •. ••L POLICY NUMBER POLICY EFFECTNE POLICY EXPIRATWN GENERAL LIABILITY "/��a • •.. ,,, AA LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ in DAMAGE TO RENTED CLAIMS MADE I J OCCURI PREMISES(Ea occurrence) $ ■ MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ III POLICY PRO- PRODUCTS-COMP/OP AGG $ • III AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ II ALL OWNED AUTOS • •625481401 7/16/201.4 7/16/2015 BODILY INJURY SCHEDULED AUTOS III HIRED AUTOS (Per person) $ 100,000 11111 NON•OWNED AUTOS BODILY INJURY III PROPERTY $ 300,000 PROPERTY DAMAGE GARAGE LIABILITY (Per accident) 25,000 ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC 'S EXCESS/UMBRELLA LIABILITY AUTO ONLY: AGG $ OCCUR []CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE $ • IIIRETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY $ ' ANY PROPRIETOR/PARTNER/EXECUTIVE IY/N' WC STA U- OTH- TORY LIMITS ER OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L EACH ACCIDENT $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-EA EMPLOYE: $ OTHER E.L DISEASE-POLICY LIMIT $ A 625481401 7/16/2014 7/16/2015 vim 25/50/10 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 2003 Mercury Sable 11FM50U83G626324 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION f axbl S($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.O Box 9034 " REPRESENTATIVES. Olympia, WA 98034 AUTHORIZED REPRESENTATIVE i Steve Jones/MJA -1/r17w ACORD 25(2003/01) INS025(2001).01 The ACORD name and logo are registered marks of ACORD 2009 RD CORPO N. All rights reserved. 9` • WATCH Search Results-No Match- Washington State Patrol Page 1 of 1 Monday, January 05, 2015 • 11,-I!IGTIIIISTITE WASHINOTON ACCESS TO CRIMINAL HISTORY Web Search No Record Found Report Washington State Patrol Identification and Criminal History Section P.O. Box 42633 Olympia, Washington 98504-2633 Telephone (360) 534-2000 THE FOLLOWING WEB SEARCH NO MATCH FOUND REPORT IS FURNISHED FOR OFFICIAL USE ONLY This report was generated from a transaction run on 01/05/2015 at 10:45 Conviction Criminal History RCW 10.97.050(1) Pursuant to the purpose of inquiry, NO Record was found in the Washington State Criminal History Repository based on the descriptors provided: FOSTER,KELLY DOB 03/28/1969 SEX M RAC U This may mean that the person you searched for has no criminal conviction record OR that your search criteria did not match the spelling of the person's name or date of birth. Positive identification or non-identification in the Washington State Patrol's database, can only be determined by fingerprint comparison. https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&Locallndex=0 1/5/2015 A ® DATE(MWDOiYYYY; CERTIFICATEOF LIABILITY INSURANCE 7/2/2015 PRODUCER 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TOP NOTCH INSURANCE SOLUTIONS I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1100 Virginia St #211 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Seattle, WA 98101 (206)264-6267 i INSURERS AFFORDING COVERAGE NAIC# INSURED FOSTER, KELLY RAY IINSJRERA National Indemnity Company i 20087 DBA KELLY KAB INSURER 8 PO BOX 1761 INSURER C• I YELM, WA 98597 INSURER D: INSURER E I COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS 'NCR ADM PCI ICY EFFECT7IV_ POL'CY EXPiRATICN LTR 'INSRO TYPE OF INSURANCE _ POLICY NUMBER fATF'MM!C^'YYW) DATE:MK CD-YYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE IS DAMAGE TO RENTED —I COMMERCIAL GENERAL LIABILITY I PREMISES(Ea=Prone) 3 CLAIMS MADE j OCCUR MED EXP(Ary one person) I 3 ---I j PERSONAL&ADV INJURY $ GENERAL AGGREGATE 3 • GEN-I.AGGREGATELIMIT APPLIES PER PRODUCTS-COMP/OP AGG 3 POLICY.'�"''�PRP 1 JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Ea✓cc ) 3 A_L OWNED AUTOS — BODILY INJURY X SCHEDULED AUTOS (Per perscn i 3 100,000 A HIRED AUTOS 71APR322396 7/3/2015 7/3/2016 IBODILYINJURY NON-OWNED AUTOS I(Per accident) $ 300,000 1 PROPERTY DAMAGE (Per acadert) 3 25,000 GARAGE LIABILITY I AUTO ONLY-EA ACCIDENT 3 ANYAUTO OTHER THAN EAACC3 'AUTO ONLY AGG 5 EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE 5 OCCUR i CLAIMS MADE ;AGGREGATE S DEDUCIBLE I RETENTION 5 $ r WORKERS COMPENSATION I WC S'LATJ- : .0TH- AND EMPLOYERS'LIABILTYY;N TORY LIMITS; ER ANY PROPRIETORPA.RTNEREXECJTIVE E.L.EACH ACCIDENT $ OFFCER'ENDER EXCLJJED-I (6Lndatory In NH) E.L.DISEASE-EA EMPLOYEE $ II yes describe..nder SPEC AL PROVISIONS be.ow E.L.D:SEASE-POLICY LIMIT $ . OTHER A UIM SPLIT 71APR322396 7/3/2015 17/3/2016 $25/$50/$10 rOESCRIPTION OP OPERATIONS 1 LOCATIONS i VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS EVIDENCE OF INSURANCE 2003 MERC VIN#1MEFM50U83G626324 CERTIFICATE HOLDER CANCELLATION DEPT OF LICENSING SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION MASTER LICENSING SERVICE DATE THEREOF.THE ISSUING IYSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN PO BOX 9034 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,au-I FAILURE TO DO 30 SHALL IMPOSE NO OBLIGATION OR LIABILITY Of ANY KIND UPON THE INSURER,ITS AGENTS OR OLYMPIA, WA 98507 REPRESENTATIVES. / , — A 1 AUTHORIZEC REPRESENTATIVE /D t //\---.; ACORD 25(2009/01) ©1988-2009 AC6RD CORPORATIONAll rights reserved. The ACORD name and logo are registered marks of ACORD State of Washington UBI # o�;; (604Z. � 3 3 63S' ,. Business Licensing Service d;::: :f!:i PO Box 9034 ass a" Olympia WA 98507-9034 Telephone:1-800-451-7985 For Hire Addendum This addendum form may only be submitted as an attachment to the Business License Application. Owner name Kelly Foster Firm/trade name KellyKah For Hire permit: Please have this form completed and signed by your local jurisdiction authority, which is the city your business is physically located in.To obtain contact information for your local jurisdiction, please visit mrsc.org/cityprofiles/citylist.aspx. Each For Hire vehicle certificate is$55.00. If you have NOT paid a For Hire Licensing fee to your local jurisdiction, you must send an additional $110.00 with this addendum for a state For Hire permit. Loc�I Jurisdiction Authority p✓ This certifies that the above-named for hire operator is approved to transport passengers for hire under provisions of local laws enacted for that purpose. ❑ This local jurisdiction partners with the Business Licensing Service and requires the for hire operator to have a City business license prior to commencing operations in this local jurisdiction. ❑ This local jurisdiction does not regulate for hire operators. VThis local jurisdiction does not regulate for hire operators that are outside the city limits. ❑ This local jurisdiction does not recognize this business as a for hire. ❑ This local jurisdiction does not regulate cabulance (medical transportation). City Official comments: fa/M/A-Z/ Signature jurisdiction authority Date oIyam4 C(L al jurisdi 1 ion/city �� Title of office P Tele hone number For assistance or to request this document in an alternate format,visit http://business.wa.gov/BLS or call 1-800-451-7985.Teletype(TTY)users may use the Washington Relay Service by calling 711. BLS-700-200 (11/21/14) ti O a r r \N:617—. l m Z W C b F. ,53m tf co CO cn ooCO id O � � 0 _J 3 �3 1-4 xc a Ci'1pz1 D s!s 1