Loading...
TIM DUSSETCHLEGER - EXP 12/2017 City of ye Cm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Tum water, and Lacey. ❑New Permit I/Renewal (Permit # J 6 - t'I 3' ) I hereby request a permit to work in the following business, trade or occupation in accordance with all laws and/or ordinances governing such business, trade or occupation in the City of Yelm.(YMC 5.03) IMPORTANT: For new permits, complete all requested fields. For renewals, complete those fields marked with a star (*) plus any other fields containing information that has changed since your last application was submitted. *PERMIT TYPE (Check one) QFor-Hire Driver ❑Locksmith ❑Solicitor APPLICANT INFORMATION *Full Legal Name: Other Name(s) Used: (If additional space is needed, use the back of this page) (F/M/L) (F/M/L) Sex M *Date of Birth 11 -2-/ 1 9 as *Age 3 t ss# LI 6° 7 s - 87 E 7 *Height s // *Weight 2 I o *Hair Color U 1'°`'I^ *Eye Color b�`-/A Place of Birth D e-a' "'''L C c, Have you ever had an occupational permit suspended or revoked? ❑Yes 21% If, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for your street address, please) *Street 'L 24 I & ✓a-' L C T k *City y l/11 *State _'4 �$ 2S3 —9c�S— 511t Cell *ZIP � 8 9 7 *Phone *Mailing address (❑same r" ° ` 0 1 � kr� qg - 47 *email 1-' " cty °C /'Lt- /6- ha 6 c °M Page 5 of 9 If you are applying for a Solicitor's Permit or a For-Hire Driver's Permit, complete the appropriate Supplemental Information section that follows. For any other type of permit, skip to the "Application Document Checklist" section. SUPPLEMENTAL INFORMATION — SOLICITOR PERMIT APPLICANTS ONLY YMC 05.03.200 Qualifications 1. Briefly describe the products or services for which you will be soliciting. 2. Please list all vehicles you will be using in your business. (Use the back of this form for additional vehicles, if necessary) Vehicle 1 Vehicle 2 Year a3 Make AA y !"P <� fir/ Model 5 4,, L I Q G S Color G sty Plate# PC t4 6 ?73 State ti 4 Owner h ,- y .y 1= s�•r Vehicle 3 Vehicle 4 Year Make Model Color Plate# State Owner Page 7 of 9 CERTIFICATION Under penalty of perjury, I swear that all information contained in this application is true, accurate and complete to the best of my knowledge and belief. I also hereby authorize the City of Yelm to conduct any reasonable inquiries, including examination of my criminal history, necessary to verify the information I have provided and determine my fitness for the permit for which I have applied. I understand that the City may, at its expense, conduct additional criminal history checks on me at any time while I hold an occupational permit issued under YMC 5.03, and I hereby consent to such checks. Signature I sAr 17 Date 1— ( I ❑ I request a copy of the criminal history data used to determine my fitness for a permit. City use only below this line Date Received I/i$1I7 Reviewed By AQN- Review Date cpApproved CI Denied Reason: ❑ complete application ❑Criminal record El Prior permit revocation El False information ❑05.03.060 ❑Other (specify) ,..tt ees paid: Permit# CI Base fee refunded:/ � Date i cPWk.ID completed : in A pplicant notified By I if �. �kl,l . --Date ( I( ( (') El Permit fee only (non-fingerprint renewal) � 1 - oo/ I Page 9 of 9 WASHIN.QTON STATE DEPARTMENT OF �• LICENSING Registration Certificate Model Year Make ModelBody Style Vehicle identification number(VIN) Scale Weight 2003 MERC SABLE 'Sedan 1MEFM50U83G626324 3,202 " Plate/Tag no Tab/Decal no Primary vehicle use type Issue date Exp date "1 I . I"' �I BCH6873 W622597 Taxi Cab 01/06/2017 01/06/2018 �, I � r � Plate/Tag • no Tab/Decal No Vehicle use type Issue date Exp date lit R � tI �I It�i ��� I' t t ++ + ;1,ll"Iiy 110 l'.111 II't1�t}� I Gross Weight Gr wt start date Gross weight exp date Fleet no Equip no Iy to '' ;`�I`I'I " i1 " [ l� int�� Vt rl i Registered Owner Legal Owner KELLY R FOSTER DBA KELLY KAB Same as Registered Owner PO BOX 1761 YELM WA 98597-1761 Brands/Comments: 21460/2003, GREEN, Display tab on back license plate only-front plate is still required,WA Prior Taxi,WA Other Anyone who knowingly makes a false statement may be guilty of a felony under state law and upon conviction shall be punished by a fine, imprisonment, or both. • I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct and, as owner or authorized agent of the vehicle, it is free of any claim of lien, mortgage, conditional sale or other security interest of any person except the person or persons set forth as legal owners. X X Kms. Signature of registered owner Signature of registered owner Date and place signed Date and place signed L0001175926 10-420-802(R/12/16)Page 1 of 2 Vehicle Information: BCH6873 1MEFM50U83G626324 2003 MERC SABLE Sedan Filing Registration Filing $3.00 Title Filing $4.00 Plate Plate Reflectivity $4.00 Original Issue Plate $20.00 Registration Registration License $30.00 License Plate Technology $0.25 Dept.of Licensing Service $0.50 Vehicle Weight $25.00 Service Title Service Fee $12.00 Title Emergency Medical Services $6.50 Vehicle Title Application $15.00 Fee Total: $120.25 You can get a copy of this cash/fee receipt detail at www.dol.wa.gov. Skip a trip—go online www.dol.wa.gov qit ACc RD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) `-+' 7/6/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Reid Woods HUMBLE & DAVENPORT INS BROKERS INCCNO No (425)226-8221 FAX No):(425)255-9342 3500 Maple Valley Hwy ADDRESS:reid@humbledavenport.com INSURER(S)AFFORDING COVERAGE NAIC X Renton WA 98058 INSURERA NewYork Marine & General ins Co 16608 INSURED INSURER B: Kelly Ray Foster INSURERC: _ DBA Kelly Kab F INSURER D PO BOX 1761 - - ' INSURER E: Yelm WA 98597 INSURER F: COVERAGES CERTIFICATE NUMBER:CL167612402 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IR TYPE OF INSURANCE ADDL SUER' POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER IMM/DD/YYYYI (MMIDDIYYYY)I LIMITS _COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ S ' DAMAGE TO RENTED CLAIMS-MADE OCCUR i PREMISES(Ea occurrence) f$ MED EXP(Any one person) 1$ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE 5 POLICY -. PRO- -�. -------- JECT i LOC PRODUCTS-COMP/OP AGO $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ----- (Ea accident) A __ANY AUTO -- BODILY INJURY(Per person) 1$ 100,000 ALL OWNEDSCHEDULED AUTOS X AUTOS AU2016TLP04101 7/3/2016 7/3/2017 BODILY INJURY(Per accident)I$ 300,000 NON-OWNED ; PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ 25,000 Underinsured motorist BI split $ 100/300 UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE — E.L.EACH ACCIDENT IS OFFICER/MEMBER EXCLUDED9 N I A 1 --- (Mandatory in NH) ! E L DISEASE-EA EMPLOYEE$ If yesdescribe under -------DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS-I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE 2003 Mercury Sable #1MEFM50U83G626324 CERTIFICATE HOLDER CANCELLATION (360)705-6699 forhire@dol.wa.gov SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Washington Department of Licensing THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Hire Program ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 9039 Olympia, WA 98507-9039 AUTHORIZED REPRESENTATIVE Reid Woods/REID _ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 imianri WASHINGTON ATE � TN�SITNG Driving Record - DUSSETW151Q7 CERTIFIEC MENT OF �• LICENSING Abstract of 3 Year Driving Record-Non-commercial This information is current as of 1/13/2017 4:05:22 PM ,r ''',B river information Driver license status PIC DUSSE-TW-151Q7 Status Clear Name Dussetschleger,Timothy W I Issued 11/10/2016 Gender Male Expires 11/27/2022 DOB 11/27/1985 Original issue date 12/4/2001 Restrictions PDL C Corrective Lenses- a. p '' Collisions Accident #of #of #of Veh At date Description Accident report# vehicles injuries fatalities Case# Vehicle class type faul 1/1/2016 Moving E500713 2 3 0 2016 01 01 0015 8/9/2016 Moving E572179 1 0 0 • We are committed to providing equal access to our services. If you need accommodation,please call 360-902-3900 or TTY 360-664-0116. If you have questions regarding your driving record,please call Customer Service at 360-902-3900. Page 1 of SUPPLEMENTAL INFORMATION — FOR-HIRE DRIVER PERMIT APPLICANTS ONLY YMC 05.03.030 Qualifications (self disclosure) Qualification Yes No 1 Have you had a valid Driver's License for the past two years? ✓ la If yes, in what state(s)? 2 Are you 18 years old? ✓ 3 Do you have any physical or mental infirmities that may affect your driving? a� 4 Have you been convicted of three (3) or more moving violations during any one (1) year period in the past five (5) years? 5 In the past five (5) years, have you been convicted of operating a motor vehicle 1f while under the influence of alcohol or drugs? In the past five (5) years, have you been convicted of having physical control of 6 a motor vehicle while under the influence of alcohol or drugs? 7 In the past five (5) years, have you been convicted of negligent driving or reckless operation of a motor vehicle? 8 In the past five (5) years, have you been convicted of vehicular homicide or assault with a motor vehicle? *M applicants must complete this section APPLICATION DOCUMENT CHECKLIST You need to do the following things before your application will be processed. Use this checklist to make sure you have all the materials you need. ❑ Submit a copy of your driver's license or, if no current driver's license, your State-issued ID card. ❑ Provide an ID photo. ❑ Have your fingerprints taken at YPD. El Submit a copy of your complete driving record (for-hire driver/operator applicants only). El Submit your completed and signed application form. ❑ Pay your fees (cash, check or debit card). Page 8 of 9 OTHER RECENT RESIDENCES List all other states and cities where you have lived in the past five (5) years. From To State City (month/year) (month/year) 1 2 3 4 5 BUSINESS INFORMATION (the business that is related to this permit) ky l^ ~ G *Business Name � `� Business Owner/CEO ! e..1'ty Is-0S be 0 Applicant StreetCity 1 1 M State WA 0.n ZIP 9 g<5 9 7 Phone ZS 3 —' 19- 2-4)441 Cell Email It `'0� k� t`� `1"6""i''Yelm Business License # EMPLOYMENT HISTORY Including your current employment, list the jobs you've held during the past five (5) years. Job Title Employer City/State From/To 1 rale, tb-, ✓4-- k./ !ly i 1&-6 ye /� , wit / 2- P _ 2a/S IL 2 5S& 's4y 06Th./.. �0.� .(1_4Ci Q1,72,1L: 1- /- ZO {S- '24-15 3 ` 1 L- A4 r#_,s Ttrtn / WA - 6'1-LJtt 4 5 *CRIMINAL HISTORY (Self-disclosure) In the past five (5) years, have you been convicted of any of the following offenses? Offense Type Yes No 1 Any felony I, 2 Larceny/theft/vehicle prowling 'I 3 Domestic violence 4 Fraud/Identity theft 5 Any drug-related crime 6 Any sex offense Y 7 Any crime against children or vulnerable adults Page 6 of 9