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MATT STEWART - EXP 12/2017 City of ye Cm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Tumwater, and Lacey. Yl w Permit glirfenewal (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) 12For-Hire Driver ❑Locksmith ❑Solicitor APPLICANT INFORMATION *Full Legal Name: (F/M/L) t /,/-4-+ /1 -PAW TS,IM e 5 Other Name(s) Used: (If additional space is needed, use the back of this page) (F/M/L) (F/M/L) Sex *Date of Birth /0 - 1 7-1 ` ? *Age S ? SS# s ci 41 07 c 5 *Height S if *Weight `� 15 *Hair Color 7 fvL,/v1 *Eye Color H-4-7_ Place of Birth Fe-r �- �, to ; 11,) Have you ever had an occupational permit suspended or revoked? ❑Yes Lilo If, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for your street address,please) *Street 010,15 re ere r id,e to 5'f *City k/- ' jM *State J, *ZIP cf €s r 7 *Phone 3GG- 9,s `i - or 6-3 Cell SALl•Yt e *Mailing address (Came *email Chr 144A-11-54---e L,.J j-c 5 T 1 0 0'A CC("e► 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 Make ��( C u cy Model 5p-13 le- Color Dk Croy Plate# C H-- 7 State j 14- Owner he l ,. 1t Vehicle 3 \ Vehicle 4 Year ``•�� Make Model Color Plate# State „`�.� OwnerNNN\ 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 / �� 1 Date 0 I - a c/ - 1 7 l ❑ 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 Alb\r1 Reviewed By It\N C C Review Date .approved CI Denied Reason: ❑Incomplete application ❑Criminal record El Prior permit revocation CI False information 005.03.060 El Other (specify) ees paid: Permit# CI Base fee refunded: Date• II al,Permit ID completed pplicant notified By s\ itV1 • \ Q 11i` Date Eq l i� CI Permit fee only (non-fingerprint renewal) u� Page 9of9 • WIi HINGTON STATE DEPARTMENT OF dL 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 J Use Mod yr Make I Body AEB1445 06/2011 M493689 06/20/2017 21460 2003 12 G PAS 2003 MERC I SAB4D Vehicle ident(VIN)/Serial no Res co Scale wt Seats Model BT Gwt I Gwt st Gwt exp Fleet Equip 1 MEFM50U83G626 4 27 3202 SD Prey plate Filing TBD RTA Tax Service fee GwtNeh 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 X .\ Signature of registered owner(s) Sig •cure of registered owner(s) Comments: USE TAX WAIVED: GIFT-COLOR-GREEN - DISPLAY TAB ON BACK L , ENSE PLATE ONLY- FRONT PLATE IS STILL REQUIRED. Validation code 03341201161800628160045019126 t p:::4,41111111 ,1 d e l < r 111, ray r r r r r r r t ) RPT ID: AREGPR-1 This certificate is not proof of ownership. e.Cr i ) + �' !I r r tr .4 VehicleReolstration(R8/14)E TD-420-802(R/1/r)Page t of 2 • Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/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 PHONE (425)226-8221 FAX (425)255-9342 (A/C.No.Ext).:_ IAIC,No, 3500 Maple Valley Hwy ADDARESS:reid@humbledavenport.com INSURER(S)AFFORDING COVERAGE NAIC N Renton WA 98058 INSURER New York Marine & General Ins Co 16608 INSURED INSURER B: Kelly Ray Foster INSURER C: DBA Kelly Kab (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 INSR TYPE OF INSURANCE 'ASDL SUER , POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER 'IMMlDDfYYYYI (MMIDpIYYYYI LIMITS II 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 S _ POLICY JECT PRO LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT • $ - -- (Ea accident) A - _ ANY AUTO BODILY INJURY(Per person) '$ 100,000 ALLOWNED . SCHEDULED AUTOS x AU70S AU2016TLP04101 7/3/2016 7/3/2017 BODILY INJURY(Peraaident)': $ 300,000 NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS • (Per accident) $ 25,000 • Underinsured motorist El split • $ 100/300 UMBRELLA LIAB OCCUR EACH OCCURRENCE ,$ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DEO RETENTIONS $ 'WORKERS COMPENSATION PER • OTH- AND EMPLOYERS'LIABIUTY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE _ - E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED') N/A - --- (Mandatory in NH) - E.L DISEASE-EA EMPLOYEE S If yes describe under `DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS-I LOCATIONS/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 I 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 INS0252-il -' WASHINGTON STATE DEPARTMENT OF CERTIFIED ci• LICENSING Driving Record - STEWAMJ370PP Abstract of Complete Driving Record This information is current as of 1/9/2017 12:33:48 PM 7 Driver information Driver license status PIC STEWA-MJ-370PP Status Clear Name Stewart,Matthew James Issued 10/15/2012 Gender Male Expires 10/17/2017 DOB 10/17/1963 Original issue date 1/17/1981 V ID status R! I Issued 4/6/2001 Expired 10/17/2005 Original issue date 4/6/2001 No violations, convictions, or accidents currently on file for this record. 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 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? 5 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? *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. 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 k 1 I \/ /�-(3 Business Owner/CEO (Iv fr S 'e. ❑ Applicant Street City State ZIP Phone Cell Email 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 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 2 Larceny/theft/vehicle prowling 3 Domestic violence 4 Fraud/Identity theft 5 Any drug-related crime 6 Any sex offense 7 Any crime against children or vulnerable adults Page 6 of 9