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TIM DUSSETSCHLEGER - EXP 12/2016 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 renewo/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$5.00 (5.02.030 A.1.) Submit photographs with application- Three recent photos must be submitted with application. (1x application,lx police dept, lx attach to license when issued) n bb.ss e-4-641 I.erlic �t2� Driver's Name 1 M'�{'L> W D &5s e 45- c, ' l f'9�— Phone number x'53-1/65 �f�l Driver's Address 2.2 y Lb /.4 c Lc17S L City,State and Zipcode y°1 M vA 145%17 Mailing Address P, ' b 57 City.State and Zipcode k 1,"'2 ) iv 9 g's ft) Valid Washington State Drivers License Number D . ' c.41 & I S i '1 (5.02.030) b(,.SSE J kit S(60 Vehicle License Tag/Plate Number C. 'vs- Proof of Ownership r Birthdate 2-7 ^l /�1 Must be at least 18 years old. Proof of Insurance Business Name and Address )1-P \k! kCt City,State and Zipcode \ tV ( , ►,,; a• Mailing Address RD jx 1--)(0 ( City,State and Zipcodey.IM t(AAA cte(591 Washington State OBI# t —.Gt..5n (o ff 1)Hove you been convicted of a felony,or of operating a motor vehicle while under the influence of intoxicating liquor or drugs or of being in actual physical control of a motor vehicle while under the influence of intoxicating liquor or drugs,or of reckless driving or negligent driving,or of vehicular homicide or vehicular assault,with five years preceding the date of application for a license? 2)Have you been convicted of three or more moving violation during any one-year period within the five years preceding the date of the application for a license? /A! 3)Are you at least 18 years with no physical or mental infirmity,which jeopardizes the ability to operate a for-hire vehicle.No person shall drive a for-hire vehicle,including limousines,within the City without first obtaining a license therefore from the City. I certify my statements are true and accurate.My signature authorizes the City of Yelm to verify any information including a driver's I' abstract. �. Signature 'Pt,/t Date / L, / 17; • C•LWASNINN1$N STATE NEtANT$tNT Nf LICENSING *. . AEB1445 Vehicle Registration.• Certificate '• .. •07/02/2015' License'platePlate Issue date Tab no : Reg expiration. Value Code .Year Mo reg Mogwt PNir:.•: Use Mod'yr. Make Body, AE81445 06/20.1,1. ' . B413611'. 06/20/2016 2.14$0 . 2003 12'' : ',G .CAB' :2003 MERG .S,AB4D Vehicle ident(VINVSerial no .Res cO• •Scale wt : 'Seats -M-odel -BT___...,,Gwf''-...•• , Gwt st .`.• .Gw..exp' ' Fleet ' Equip 1MEFM50U83G626324. 27 3202 ..7''.49,::,; p -• ,• Prey plate Filing :IBD RRA Tax 1-. 4 ' `;.`" 011SET $3 00 ,�; 'l�Saa`nilTseflaq; .ri' eh`wt'• Other Totalfels8' :Gwtcr • . ,.'• y,.. .-:::.:•14:::-.45450-4;:::.-:11';$1,6:40' .$30:75. ..s.$48.-Z5 • - 1 r .. . .:: %vim... y J; <'.' ��•,. ..�. FOSTER,KELLY'RAY QB� .�ii` "`' ' • ` :KELLYKAB '•.} i; i• r . li it a:_ll '1,11.—':••••,••••••• P.O 80X`1781' :v ci. _ _Ii-li i' ;r,r. ••"_'+ :t,i - -. YEA'.WA'88597 4 • - ' • *: ,i.. .t '= • '-';. - -' `i.>;':;S.•• .,..f 1if.:,...': a..:`•, ii •is • - . • . _ .. "•y i•.:: :',:�,e.'.n.o w.. Cy .. I..,:'''' • • .:;,..., :;..:..vii... -:=.,. '!-.1W►.+-4-.;,.wf-•..Sr.-e:u.:•.s ' +—... �• • •i' a -l.. '1 l+ •`.it , ---..., . —1, 1, •i: i -_ Signature of stared owns s) _.11. . i i nature of re I t .. • ,_.1_.,...• •w, Sgregisteredowner(s� Comments: r..4i: ;,. _ `al,; CALOR=GREEN;DISPLAYTAB C4 ACK LICENSE PL TE;ONLY-FRONT PI.ATE;IS STILL REQUIRED. .' .' .....,,. `` .• ..-.-_. `� .I' 4`� • Validation code 03341201 151830702150022012327. ` {1r;+r;+�;, ,r,+' ,+�;+ 1 .�i'r'rrr4':+ + +f;+f;M;+ + • RPT ID: AREGPR-1' This certificate'is not proof of ownership, • 'r4'rrliir+ +, +rrt 1 ,wo I •t+ VehlcleRegistraiiOo.(FV8/i4)E . ' '• -. . ; TD 420 1102(R/t/t 2)Rags.i M 2 . Acd t: CERTIFICATE OF LIABILITY INSURANCE DATF(MWDD,YYYY) 7/2/2015 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TOP NOTCH INSURANCE SOLUTIONS 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 INSURERS AFFORDING COVERAGE NAIC! INSURED FOSTER, KELLY RAY INSURER A National Indemnity Company 20087 DBA KELLY KAB INSURER 8: PO BOX 1761 INSURER C: YELM, WA 98597 INSURER D:' I INSURER E: 1 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. ILYE BOOT— LYE am TYPE OF INSURANCE POLICY NUMBER ITAT�E(MMr g'IC Y)E DA_ ( LIMITS GENERAL LIABILITY • EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAI/WAGE TO RLN LLD PREMISES(Ea opcuneriCe) S CLAIMS MADE 1 I OCCUR MED EXP(My one person) S PERSONAL&ADV INJURY S GENERAL AGGREGATE 3 GEN!.AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S } 7 POLICY 7 JECT 7 LOC AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ ANYAUTO . (Ea accident)ALL OWNED AUTOS —+ BODILY INJURY X SCHEDULED AUTOS (Pr person) S 100,000 A HIRED AUTOS 71APR322396 7/3/2015 7/3/2016 BODILY INJURY NON-OWNED AUTOS • (Per occident) i 300,0001 1 PROPERTY DAMAGE (Per accident) f 25,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT I I ANYAUTO EA ACC S OTHER THAN AUTO ONLY: AGO S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR n CLAIMS MADE AGGREGATE i f f DEDUCTIBLE S • RETENTION S S —, DWOR EMPLOYE KERS S'LIABIL ENSATION YIN T STATU-I$f !OERN- ANY PROPRIE70RMARTMERAIXECUTIVE E.L.EACH ACCIDENT S OPP ICIRAAEVIBER EXCLUDED? (M'n°tory In ron E.L.DISEASE-EA EMPLOYEE f n .s d.EcHb.ur d.r SPECIAL PROVISIONS below I E.L.DISEASE-POLICY LIMIT S ^�OTHER I A UIM SPLIT 71APR322396 7/3/2015 7/3/2016 $25/$50/$10 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS EVIDENCE OF INSURANCE 2003 MERC V1N#1MEF1150U83G626324 CERTIFICATE Hs.DER CANCEL •TION S HOULD ANY OP THE ABOVE DESCRIBED POUCIES IIS CAS� E E ND BEFORE THIS DEPT OF LICENSING 30 DAYS WRITTEN • THEREOF,THE INSURER URER WILL ENDEAVOR TO MAIL MASTER LICENSING SERVICE PO BOX 9034 NOTICE TO THE CERTWFICATI MOLDER NAMED TO THE LEFT,OUT FAY.URE TO DO SO SMALL IMPOSE NO O8 JGATION OR LIABILITY Of ANY KIND UPON THE INSURER,In AGENTS OR OLYMPIA, WA 98507 RWRE.IENTATIVI$. n AUTHORIZED REPRESENTATIVE• �i \\\ I \ ACORD 25(2009101) ©1988-2009 ACgRD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Page 1 of 1 lir W T C WASHINGTON ACCESS TO CRIMINAL HISTORY Web Search No Record Found Report Washington State Patrol Identification and Criminal History Section P. 0. Box 42633 Olympia, Washington 98504-2633 Telephone (360) 534-2000 Option 2 THE FOLLOWING TRANSCRIPT OF RECORD IS FURNISHED FOR OFFICIAL USE ONLY This report was generated from a transaction run on 1/11/2016 at 8:55 AM 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 descriptors provided: DUSSETSCHLEGER,TIMOTHY W DOB 11/27/1985 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/Home/PrintResponse?Search=2&PurposeCode=V&Que... 1/11/2016 CD lA, �1 b ly C r ry e b 0 ca 0 it Nrm ,0-4-1N xi 0 1 ti cA, 1_, t.., ct o b ti)„._ z. v),.,_, k_kiy W (O H` CJ N o co c::, ''c r�-�--I At0 < o 2. �.J cr,00 J - < w < 3tll 4, ri) pm, ... xc . O. tri Dy % /o 1 � �