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KELLY FOSTER - EXP 12/2017 City of yeCm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Tumwater, and Lacey. ❑New Permit XRenewal (Permit# \U211 ) 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. 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 ❑Locksmith ❑Solicitor APPLICANT INFORMATION *Full Legal Name: (F/M/L) - Other Name(s) Used: (If additional space is needed, use the back of this page) (F/M/L) (F/Mn/L) Sex1r \ *Date of Birth` 28I *AgekAl # 3 *Height`p 5 ` *Weight 32-g *Hair Color c..Q *Eye Color 0 Place of Birth \ 0k)CAYyNN Have you ever had an occupational permit suspended or revoked? ❑Yes 1)-ii No If, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for your street addre s, lease) *Streetlae,1\ Vicvwvk .f City 54, WI ktwPA *State(AJ *ZIFQ *Phone Z ---71a` O-\ Cell *Mailing address (❑same TUX fl A ) von 9, 1 *email v1-0‘ , 16 , 'c- qtykott.A ( CO"yyl Page 6 of 10 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) *Business Name Y---.. \\\)\k�b Business Owner/CEOF—`e� Kplicant Street. 'E U L City 9,0\0-1 State 1 ZII4gr54---1 Phone3 HO;2 Cell Email K-8\-\(:), \C-.C.\\A\C4\3‘6:9nielm Business License# 11- 16�CV-1 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 AV) !Z,\\ 1(-400 ��a� 1A.44- 7 d r) '9.A-P8— 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 N� 1 Any felony 2 Larceny/theft/vehicle prowling 3 Domestic violence 4 Fraud/Identity theft 5 Any drug-related crime 6 Any sex offense VA 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? 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? 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? 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 Page 9 of 10 WASHINGTON DRIVER LICENSE as LIC#FOSTEKR313D8 -1FOSTER 2 KELLY RAY 3 DOB 83.28-1969 4a Isa._ 3Q6119R SSTUNIT C MCKWRA WA 065584111 15Sex M 16 Hgt 6" }17 Wgt 3NM 18 Eyes = i 4 Class 9a End NONE 12 Restrictions C 46 • 5 CO FoStExR31 LICENSING STATE DEPARTMENT Driving Record - FOSTEKR313D8 CERTIFIED � • CENAbstract of 3 Year Driving Record-Non-commercial This information is current as of 1/10/2017 12:24:00 PM Driver information Driver license status PIC FOSTE-KR-313D8 Status Clear Name Foster,Kelly Ray Issued 6/22/2012 Gender Male Expires 3/28/2017 DOB 3/28/1969 I Original issue date 7/12/1994 Restrictions PDL C Corrective Lenses- 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 CgWASHINGTftN STATE DEPARTMENT OF s 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 , A l BCH6873 W622597 Taxi Cab 01/06/2017 01/06/2018 Issue date Exp date ' '1'1�I�, i �i�1, Plate/Tag no Tab/Decal No Vehicle use type '6''+ �I 111 �r , Gross Weight Gr wt start date Gross weight exp date Fleet no Equip no •iy, i^I �, p,I,l� ti " V ll 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 Signature of registered owner Signature of registered owner 1 v,-e ?vyn Date and place signed Date and place signed L0001175926 TD-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: 5120.25 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 ACC)RD DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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 INC PHONE (425)226-8221 FAX (425)255-9342 (A/C.No.Extp_._ (A/C,No): 3500 Maple Valley Hwy ADDRESS:reid@humbledaVenport.Com INSURER(S)AFFORDING COVERAGE NAIC# Renton WA 98058 INSURER A:NEM York Marine & General Ins Co 16608 INSURED INSURER B: Kelly Ray Foster INSURERC: DBA Kelly Kab „INSURER D: _ -- - 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. IR TYPE OF INSURANCE ADDL SUBRI POLICY EFF POLICY EXP LIMITS LTR INSD WVD�� POLICY NUMBER (MMIDDIYYYY) (MMfDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S C-AIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) S PERSONAL&ADV INJURY $ GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- _ LOC PRODUCTS-COMP/OP AGG $ JECT OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) A Imo _ANY AUTO j BODILY INJURY(Per person) $ _ 100,000 ALL OWNED x SCHEDULED AU2016TLP04101 7/3/2016 7/3/2017 BODILY INJURY(Peraccident)t S 300,000 ,AUTOS AUTOS _ NON-OWNED I PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) • $ 25,000 Underinsured motorist BI split 5 100/300 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE! AGGREGATE S DED RETENTION S j WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITYV/N _-_ STATUTES ER !ANY PROPRIETOR/PARTNER/EXECUTIVE - E L.EACH ACCIDENT $ 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 $ DESCRIPTION OF OPERATIONS-/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 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 INS0251Omani% 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. Suyour a copy of your driver's license or, if no current driver's license, State-issued ID card. Q Provide an ID photo. 17H ve your fingerprints taken at YPD. Submit a copy of your complete driving record (for-hire driver/operator applicants only). 24-ubmit your completed and signed application form. Pay your fees (cash, check or money order). 1 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 111E-1101 Date 1, IC.- 11 V( 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 On Reviewed By ` .Cl..i'4Review Date 1` ( t1 c_DApioved ❑Denied Reason: ❑Incomplete application ❑Criminal record ❑Prior permit revocation ❑False information 005.03.060 ❑Other (specify) (9 Fees paid: Permit# El Base fee refunded: Date 'Permit ID completed /Applicant notified By ► ,Ref c VV- Date a tq 11---) ❑Permit fee only (non-fingerprint renewal) Page 10 of 10 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. - Xt 01QAP , 5 Vic. S 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 ?ars Make ,/fin u �� Model C \ jou Color ?, Plate# State (� l_ Owner K,) ccis\_,►ir-v144 `J ,I'(„\v Vehicle 3 Vehicle 4 Year Make Model Color Plate# State Owner Page 8 of 10 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 get your 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 be valid. • Occupational permits are not business licenses. It is your responsibility to either 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. • Occupational permits may be suspended (i.e., taken away temporarily) or 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] Page 5 of 10