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SHEILA JOHNSON - 12/2017 City of ye Cm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Tufnwater, and Lacey. l New Permit ❑Renewal (Permit# ) 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) N1For-Hire Driver ❑Locksmith 111 Solicitor APPLICANT INFORMATION *Full Legal Name: �--� (F/M/L) V ( ll.l la L �OVtY O V Other Name(s) Used: (If additional space is needed, use the back of this page) (F/WL) °A {� kap k.-t-P1 r t (F/M/L) S1'1/11\i Rae, YO,€ x sOY1 /Skia RaP_ OJr �C . Sex *Date of Birth Cn i O /1 C1-1 I *Age q SS# 53'-{=78- 110 5= *Height 1' is" *weight 24) *Hair Color 13 R- *Eye Color ,v L-IA Place of Birth L-C--LA.)lS +brl .a1(\(� Have you ever had an occupational permit suspended or revoked? EYes ❑No If, "yes," when and where 471- Z©O3 cDY Hca\`ex P v Lk O HOME ADDRESS (Do not use a P.O. Box for your street address,please) *Street 1 1 Z-'L S• A/ 1 f.W 1r. *City t4 e,� (4 *State lan *ZIP `a 59—1 *Phone( O 5j q• ' 2 Cell (zbs) 5.1 L1- q 7 3 2 *Mailing address (ikisa m_e *email cmelti IY'�SvlPratie ra toot CbIM 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. Ia X l l_._O lel.r 1 aY 11/2 '' 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 7 of 9 •r 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. def ikti ) 1, • ! Date 571 / 7 0 I request a copy of the criminal history data used to determine my fitness for a permit. City use only below this line Da Received Slt\ 11 Reviewed By �, 1\ikiReview Date d���� Approved ❑Denied Reason: ❑Incomplete application 0 Criminal record ❑Prior permit revocation ❑False information 005.03.060 ❑Other (specify) 1 .1 Fees paid: Permit# n -03b ❑Base fee refunded: Date 2ermit ID completed - .Applicant notified By *. §..;---- InDate ��4L � ❑Permit fee only (non-fingerprint renewal) Page 9 of 9 IVASHINGTON MENT OF a LICETN�SITNG Driving Record -JOHNSSR295ME CERTIFIED Abstract of 3 Year Driving Record-Non-commercial This information is current as of 2/27/2017 11:46:14 AM Driver information Driver license status PIC JOHNS-SR-295ME Status Clear Last JOHNSON Suffix Issued 8/22/2014 First SHEILA DOB 7/5/1971 Expires 7/5/2020 Middle RAE Gender Female Original issue date 7/1/2014 ID status _. Issued 5/23/2012 Expired 7/5/2016 Original issue date 5/23/2012 Tickets Violation Licensing Exempt Veh date Violation# Description Court finding Court name Court type BAC THC state veh type 11/7/2014 4Z0971231 Registration violation-no Conviction 1/13/2015 Roy Muni Court Municipal tabs Comments DateComment 12/12/2006 Moved out of state to ID1.Returned to WA on 7/1/2014 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 1 J WASHINGTON STATE OEPAHTMEHT OF d. LICENSING AEB1445 06/28/2016 Vehicle Registration Certificate License plate Plate Issue date Tab no Reg expiration Value code Year Mo reg Mo gwt Pwr Use Mod yr Make Body AEB1445 06/2011 M493689 06/20/2017 21460 2003 12 G PAS 2003 MERC SAB4D I Vehicle ident(VIN)/Serial no Res co Scale wt Seats Model BT Gwt Gwt st Gwt exp Fleet Equip 1MEFM50U83G626324 27 3202 SD Prey plate Filing TBD RTA Tax Service fee GwWeh wt Freight Proj Other Total fees Gwt cr 011 SET $3.00 $5.00 $10.00 $30.75 $48.75 • FOSTER,KELLY R PO BOX 1761 • YELM WA 98597 • • Si nature of registered owner(s) Signature of registered owner(s) Comments: USE TAX WAIVED: GIFT-COLOR-GREEN - DISPLAY TAB ON BACK LICENSE PLATE ONLY- FRONT PLATE IS STILL REQUIRED. 1111: Validation code 03341201161800628160045019126 I RPT ID: AREGPR-1 This certificate is not proof of ownership. tt I VehicleReoistration(R/8/14)E TD-420-802(R/1/Q)Page 1 0'2 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 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 NAME: HUMBLE & DAVENPORT INS BROKERS INC A Nc Ext) (425)226-8221 gICNoI:(425)255-9342 (pl3500 Maple Valley Hwy AMNMSS:reid@humbledavenport.com INSURER(S)AFFORDING COVERAGE NAIC# Renton WA 98058 INSURER A:NAM York Marine & General Ins Co 16608 INSURED INSURER B: Kelly Ray Foster INSURERC:DEA Kelly Kab INSURER o: PO BOX 1761 INSURER E: Yelm WA 98597 INSURERF: 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. INSR ADDL SUER POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) IMMIDD/YYYY)'. LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) ° MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ • POLICY I PRO-JECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acddent) ANY AUTO BODILY INJURY(Per person) $ 100,000 A ALL OWNEDSCHEDULED 1, AUTOS R .AUTOS AU2016TLP04101 7/3/2016 7/3/2017 BODILY INJURY(PeraccideM)}$ 300,000 NON-OWNED PROPERTY DAMAGE 1$ 25,000 ' HIRED AUTOS AUTOS _(Per accident) Underinsured motorist Bl split $ 100/300 UMBRELLA LIAB OCCUR EACH OCCURRENCE i$ EXCESS LIAB CLAIMS-MADEI AGGREGATE $ DED RETENTION§ i {, S WORKERS COMPENSATION 1 IPER 0TH- AND EMPLOYERS'LIABILITY SSTATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A E EACH ACCIDENT OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYEE If yes describe 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/RET_D _©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSn25,;men-, • • 41.f. I 1 LTA WASHINGTON DRI VER LICENSE 4d LIC#JOHNSSR295ME DONOR V • 1JOHNSON 2 SHEILA RAE 3 DOB 07-05-1971 07.01-2014 815722 SE VIEW DR YELM WA 98597-9810 - - 15 Sex F 16 Hgt 5.06 17 Wgt 285 18 Eyes BLU 9 Class 9a End NONE ac Exp 07-05-2020 12 Restrictions NONE •/ 5 DD J0HNSSR295ME3114182401042 Rev ns.16-2nn9 • • 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)? b0a4i ncyt,on 2 Are you 18 years old? X 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? 5 In the past five (5) years, have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs? x 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? 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. ❑ Submit a copy of your complete driving record (for-hire driver/operator applicants only). ❑ 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) N ►Ps 2 3 4 5 BUSINESS INFORMATION (the business that is related to this permit) *Business Name lti Business Owner/CEO I/1.M I " cosk e'- ❑ Applicant Street p ()A:2)OX h (o I City ipti(y\ State(d) ZIP ��son Phone 3( O ` 15- Cell Email \`lt\t °C V�,IIka O,(. 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 3e1c 1 Thr.de Cuber,LLC. Rs str Taci3 lU fl 20 I Z017 2 17eacs�,` ra�nsiorka-t-Idh (13. r tc &t 01 IA 1 2.0 Its 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 X 2 Larceny/theft/vehicle prowling 3 Domestic violence X 4 Fraud/Identity theft 5 Any drug-related crime k 6 Any sex offense k 7 Any crime against children or vulnerable adults X Page 6 of 9 • • City of yeCm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Tumwater, and Lacey. 1 New P mit ❑Renewal (Permit# ) 1151 - 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) NI For-Hire Driver ❑Locksmith ❑Solicitor APPLICANT INFORMATION *Full Legal Name: `� (F/M/L) 1 l �L va VIM©yt Other Name(s) Used: (If additional space is needed, use the back of this page) (F/M/L) %Le') k ae, rJ L (F/M/L) S�Lk �i ie, nceys /Ska Ra P. L' 1 i k Sex *Date of Birth b"110511 qi I *Ageq 5 SS# E31—i 110 T *Height 1Lal' *Weight 2N( *Hair Color j3 (Z *Eye Color ,% LIA Place of Birth \--e-t As `ori I '\(`) Have you ever had an occupational permit suspended or revoked? [ Yes ❑No If, "yes," when and where i:7'--ZO63 cor cal\&.,r \ P acilC 1,\ lrl Y--\- 1 HOME ADDRESS (Do not use a P.O. Box for your street address,please) *Street 1 '� Z2 S•G.LI t U) *City t4 e AA *State 13.6 *ZIP ea 5-9 *Phone(703)5-114 - 97,q 2- Cell (24A) -q 2 *Mailing address (Elsame O *email A e. A ti 1 t('tS YlP Yc"1 tit* ItC6� �>M Page 5 of 9 I . 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. aX I Courter ay•,vex 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 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 (b) S/ 4 I Date c:/— 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 Reviewed By Review Date ❑Approved El Denied Reason: ❑Incomplete application ❑Criminal record El Prior permit revocation El False information ❑05.03.060 ❑Other (specify) El Fees paid: Permit # El Base fee refunded: Date ❑Permit ID completed ❑Applicant notified By Date ❑Permit fee only (non-fingerprint renewal) Page 9 of 9 • You may request a copy of the criminal history record check data that was used in determining your fitness for a permit by checking the box in the "CERTIFICATION" section of the application at the time you submit the application. If you request this data, you will receive a copy at the time you pick up your permit. If your permit is denied and you requested a copy of your criminal history data, you will need to pick up your copy in person at the Police Department within ten (10) working days of the time you receive your denial notice. The City destroys this data after a decision has been made to issue or deny a permit, so, unless you request a copy at the time you submit your application, \AIM nn+ hn hinr to nrn_nrie ,r u ii _Arith a ropy of yni it rrirninal hiQtnry data Things to Know About Your Permit • Permits are good for the calendar year of issue only. It is your responsibility to get a new permit each year. No reminders or renewal notices are sent out. You can apply for renewal any time after October 1. Plan ahead to net yo i permit renewed well before the start of each new year. • 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 he valid. • Occupational permits are not business licenses. It is your responsibility either to have an appropriate, valid business license yourself, if required, or to be working under a valid business license issued to your employer. • Some occupational permits have specific rules and regulations pertaining to how and when they can be used. It is your responsibility to be familiar with the rules and regulations that apply to your permit type. [see YMC Chapter 5.03] www.ci.yelm.wa.us or request a copy. • Orri ipatinnal permits may he ci icr anrieri (i.e.. taken away temnnrarilvl nr revoked (i.e. taken away permanently). It is your responsibility to make sure you know the conditions 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. • Finally, misuse of Occupational Permits can result in civil and/or criminal liability. Be sure to follow the rules, regulations and requirements in the Yelm Municipal Code. [see YMC Chapter 5.03.300] Dann A of Q 1 Occupational Permits (YMC 5.03) APPLICATION INSTRUCTIONS New Applications • You must submit a "new application" if any of the following apply to you: 1) You are applying for an occupational permit for the first time; or 2) You had a permit in previous years but did not have one last year; or 3) You had a permit last year but it was suspended during the year. • If vou are required to submit a "new application," check the "New Permit" box, and complete all the information requested on the application form. • If you checked Solicitor or For Hire Driver in the permit type, be sure to complete the appropriate Supplemental Information section. • Get your fingerprints taken by Yelm PD with Picture ID required. This must be completed before your application will be processed. Yelm PD does fingerprinting from 9:00 am through 11:00 am and 1:00 pm through 3:00 pm depending on staff availability; Tuesday through Thursday. No appointment is necessary. Proof of$10.00 payment must accompany service. • Driver For Hire, applicants must submit a copy of their complete driving record. This record may be obtained from the Department of Licensing and will require the payment of a fee at the applicant's expense. This requirement applies only to For Hire vehicle driver/operator permit applicants. Bring your application materials to the City Business License service counter to turn them in; you can pay your permit fee by check, cash or money order at the service counter. if you submit your application materials by mail, enclose a check or money order for the amount of the permit fee and any other applicable fees. Make checks or money orders payable to the City of Yelm. • Permit fees. The current initial fee for the Occupational Permit is $70.00 per year and any portion thereof. ($10.00 Permit fee; $50.00 WSP/FBI record check fee; $10.00 for 2 fingerprint cards), plus a separate $35.00 City of Yelm Business Liei IJC Application to do business in Yelm). • If you pay by check, be aware that your permit will not be released to you until your check clears. Permit Renewal • V... eligible +�. + + II n+fh� 4�II�.�i•nn v'vl lei t� ► ou are eligible o renew your permit it all of a is IVIIVVVii ig appiy o you. 1) You have a permit issued by the City last year for the same occupation that you're applying for this year; and pane 2 of Q 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)? Ii0a->11 l Witnn 2 Are you 18 years old'? J 3 Do you have any physical or mental infirmities that may affect your driving? three (3) or more moving violations during any one Have you been convicted of 4 (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? 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? *A!! 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. - U 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. O Submit a copy of your complete driving record (for-hire driver/operator applicants only). ❑ 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 N (p 2 13 4 5 BUSINESS INFORMATION (the business that is related to this permit) *Business Name V e l l Business Owner/CEO `\e,tt Ij coske‘r- El Applicant Street 7 V)O)C Il (o\ City P 0A State(A) ZIP ctif 5c 1 Phone ADO ` - `et 15 Cell Email Vyt\tt °C c:,0\jKa O,�. Yelm Business License# J 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 2 3.€.Icem 10 +,re f a ;uty kube)Li_e, Riistr 'racow, fl W It/z0i7 ' PeacA, ra S iot-A- -: c3/! (-1) DLI't l/� l iAi vl O i a3 IA 1 t'� Z� 1�r W t� 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 2 Larceny/theft/vehicle prowling 3 Domestic violence 4 Fraud/Identity theft 5 Any drug-related crime k 6 Any sex offense , k 7 Any crime against children or vulnerable adults j X Page 6 of 9