WESLEY SNOW - EXP 12/2017 City of "Yelm
OCCUPATIONAL PERMIT APPLICATION
Permits issued by the City of Yelm are valid in Yelm, Olympia, Tum water, and Lacey.
New Permit I2genewal (Permit # \ 5"1
1 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.
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) ❑For-Hire Driver I2 ocksmith ElSolicitor
APPLICANT INFORMATION
*Full Legal Name:
(F/M/L) LD�-SI j \(Y\AA St\)0t,�
Other Name(s) Used: (If additional space is needed, use the back of this page)
(F/M/L)
(F/M/L)
Sex 1", *Date of Birth CI I 1.17 *Age Q11 SS# :3L- 43 - 15111
*Height ,l` I)" *Weight ) 12)' *Hair Color QiRAY *Eye Color _13/tot2 n]
Place of Birth M,q 01/4)40{
Have you ever had an occupational permit suspended or revoked? ❑Yes PKo
If, "yes," when and where
HOME ADDRESS (Do not use a P.O. Box for your street address, please)
*Street 1 y 73q SAID M// RD ,;_ *City YPin) *State ka.
*ZIP 9Ry T7 *Phone rv" a� -i -Pl o,,5 Cell „V Li-SS-
*Mailing address (❑same e,o, SOX (043 �1 97
*email SA10 W( n) ( 1 ! aoo1j 'c `'Af(o. ct M
Page 6 of 10
OTHER RECENT RESIDENCES
List all other states and cities where you have lived in the past five (5) years.
State City From To
(month/year) (month/year)
1
2
3
4
5
BUSINESS INFORMATION (the business that is related to this permit)
*Business Name CJ 11)T •)-00 1 j r}J
Business Owner/CEO Ls/8.y Q• ,S )O1.0 C"Applicant
Street I H1739 $'A)p ht r)) RD. City LitI j State OR.
ZIP q/ Phone 3649- lty Cell 360- Yk-a,s8.
Email Snooty A) ,q c nc f`� Yelm Business License #
EMPLOYMENT HISTORY Le4Ip. COM
Including your current employment, list the jobs you've held during the past five (5) years.
Job Title Employer City/State From/To
1 1- Mira C(IniTS i-Cr M7'/f q1I , OP- ),o0 0)'7
2
3
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 V
2 Larceny/theft/vehicle prowling
3 Domestic violence ✓'
4 Fraud/Identity theft V
5 Any drug-related crime V
6 Any sex offense ✓
7 Any crime against children or vulnerable adults
Page 7 of 10
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?
1a 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?
4 Have you been convicted of three (3) or more moving violations during any one
(1) year period in the past five (5) years?
In the past five (5) years, have you been convicted of operating a motor vehicle
while under the influence of alcohol or drugs?
6 In the past five (5) years, have you been convicted of having physical control of
a motor vehicle while under the influence of alcohol or drugs?
In the past five (5) years, have you been convicted of negligent driving or
reckless operation of a motor vehicle?
In the past five (5) years, have you been convicted of vehicular homicide or
8
assault with a motor vehicle?
*M applicants must complete this section
Page 9 of 10
' f
usa WASHINGTON DRIVER LICENSE
A'• £4,1 LJC#SNOW*WD53909
SNOW
p?WESLEY D
ooe 09-20-1947la� 98-26-2913
14739 BALD HILL RD SE
YELM WA 98597-8979
Sex M is Hgt 6-e0
• W gt 200 18 Eyes HAZ
Class 9a End NONE
12Restrictions NONE "' xl`99-29-2018
7T7r 4 •Vv
s DO SNOW'WD539oe32132387H2966 Rev 69-16-2969
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
Make
Model
Color
Plate#
State
Owner
Vehicle 3 Vehicle 4
Year
Make
Model
Color
Plate#
State
Owner
Page 8 of 10
•
Thin s to• Know About Your Permit
Permits are good for the calendar year of issue d noticlt is your es are sent out. s bnl►, can apply for
ity to get a
new permit each year. No reminders or renewal
renewal any time after October 1. Plan ahead to get your permit renewed well before
the start of each new year.
4 • There is no grace period for renewing a new permit. Current year permits expire at
midnight on December 31, and you cannot lawfully engage
in a permitted occupation
after that time until you have your renewed permit in hand.
• Permit fees are for the calendar year of issue (or any part thereof). Fees are not
prorated.
• Renewal stickers must be affixed to the permit card in the proper location in order to be
valid.
• Occupational permits are not business licenses.lf It
idy your rered, sponsibility
nsbe working to
either
have
an appropriate, valid business license yourself, q
valid business license issued to your employer.
• w
Some occupational permits have specific rules and regulations am liar wittertae u esining o ho and
when they can be used. It is your responsibility to b
regulations that apply to your permit type. [see YMC Chapter 5.03]www ci yelm.wa.us
or request a copy.
• Occupational permits may be suspended (i.e., taken r (know the conditions
ly) or revoked (i.e.,
taken away permanently). It is your responsibility tomake sure you
that can lead to those actions. [see YMC Chapter 5.03.060]
• Occupational permits issued by the City of Yelm are valid in Yelm as well as Olympia,
Tumwater, and Lacey.
• ility.
Finally, misuse of Occupational Permits can result in civiln and/or
d/orYelcriminal
Muci al liabCodeB[see
sure to follow the rules, regulations and requirements
YMC Chapter 5.03.300]
Page 5 of 10
APPLICATION DOCUMENT CHECKLIST Use this checklist to
You need to do the following
things before your application will be processed.
make sure you have all the materials you need.
yZr Submit a copy of your driver's license or, if no current driver's license, your State-issued ID card.
/Provide an ID photo.
0 Have your fingerprints taken at YPD.your complete driving record (for-hire driver/operator applicants only).
0 Submit a copy of
JZ/S bmit your completed and signed application form.
Pay your fees (cash, check or money order). -ma j
CERTIFICATION application is true, accurate and
authorize the City of to and
Under penolty of perjury, I swear that aandfbelief.oI also n the herebythis nCity Yry mto verify the
ato abl best t my knowledgecriminal history,
completeexamination of my for which I have applied. I
any reasonable inquiries,rod including fitness for the permit
information I havetthe provided cadpedetermine myconsent k such eha an
time
understandweI that City may,o
at its expense, conduct additional criminalerebhistory checks on me a any
ks.
time while I hold an occupational permit issued under YMC 5.03, and
Date r
Signature
❑ I request a copy
of the criminal history data used to determine my fitness for a permit.
City use only below this line --------------
Review Date
Reviewed By 1•
Date Received �
LVApproved 0 Denied Reason: 0—Incomplete application ❑Criminal record
❑Prior permit revocation 0 False information
❑05.03.060
❑Other (specify)
p2f,p
❑Base fee refunded: Date
Fees paid: Permit# _ Date `
A plicant notified By Ile , Gv
ermit ID completed ,� p
❑Permit fee only (non-fingerprint renewal)
Page 10 of 10
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