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KELLY FOSTER - EXP 12/2018 City of YeCm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Ye/m, Olympia, Turnwater, and Lacey. El New Permit [2(enewal (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) r-Hire Driver El Locksmith El 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/MIL) (FIM/L) SedA *Date of Birth kC1 01 *AgeLQ) SS# ct-)\2•3 t 12- *Height _ *Weight 3 IcA *Hair Color . )IA-6A*Eye Color 33-vfivt Place of Birthszisrmk.Av\av• C2AZicsPrN Have you ever had an occupational permit suspended or revoked? LII Yes No If, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for your street address, please) *Street.351.0 \\ S ‘a..)--) Wm. *City 1\\C*---cvv-NcN *State(,U *ZIPC: St-S-1S *Phone t25x3---\ Cell *Mailing address (Elsame Tb Z04. \.) -C.,\0^ LAM C‘V3CCI Q-P \ ic6)- *email\ \y _0..No -.e_X Page 5 of 9 OTHER RECENT RESIDENCES List all other states and cities where you have lived in the past five (5) years. 1 From To State City (month/year) (month/year) 2 3 4 5 BUSINESS INFORMATION (the business that is related to this permit) *Business Name •.•(,„\\v\ CA,‘r Business Owner/CEO \‹-e--\\-1\ o Applicant Street 22,7. E k-N-GStrIn Y14JE City \A‘CAYN Stat ZIKAce-Ydn Phonerk) -MC Cell EmaikCA\e.kCA\1 GlY/A Yelm Business License# - 10SW) 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 . ).i.rt-1/4 [Lxvi Zc K7 - PAcifit 4 " 6 *CRIMINAL HISTORY (Self-disclosure) In the past five (5) years, have you been convicted of any of the following offenses? Offense Type Yes No I Any felony 2 Larceny/theft/vehicleprowling 3 Domestic violence 4 Fraud/Identity theft 5 Any drug-related crime 6 Any sex offense V 7 Any crime against children or vulnerable adults Page 6 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. -St4 SCA•3\-(j4 2. Please list all vehicles you will be using in your business. (Use the back of this form for additional vehicles, if necessary) Vehicle I Vehicle 2 Year .2.cr-5 Make Model ColorPlate# x,z4 ) State iNn Owner Vehicle 3 Vehicle 4 Year Make Model Color Plate# State Owner Page 7 of 9 SUPPLEMENTAL INFORMATION — FOR-HIRE DRIVER PERMIT APPLICANTS ONLY YMC 05.03.030 Qualifications (self disclosure) Qualification __— Yes . No j 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? TT Do you have any physical or mental infirmities that may affect your driving? r/ 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? *AII 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. Li Submit a copy of your complete driving record (for-hire driver/operator applicants only). ❑ Submit your completed and signed application form. El Pay your fees (cash, check or debit card). Page 8 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 occup4tional permit issued under YMC 5.03, and I hereby consent to such checks. / Signature Date I Li 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 DApproved CiDenied Reason: ClIncomplete application OCriminal record ElPrior permit revocation OFalse information D05.03.060 E Other (specify) LiFees paid: Permit# Li Base fee refunded: Date OPermit ID completed DApplicant notified By Date CI Permit fee only (non-fingerprint renewal) Page 9 of 9 `� 6$ ACCIRl7 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 6/27/2017 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 Timothy Reid Woods NAME: HUMBLE & DAVENPORT INS BROKERS INC PHONE (425)226-8221 FAX (425)255-9342 IANC.No.Ext): (AIC,No): 3500 Maple Valley Hwy nDMRless:reid@humbledavenport.com INSURER(S)AFFORDING COVERAGE NAIC# Renton WA 98058 INSURER ANeW York Marine & General Ins Co 16608 INSURED INSURER B: Kelly Ray Foster, DBA: Kelly Kab INSURERC: PO BOX 1214 INSURER D: INSURER E: Yelm WA 98597 INSURERF: COVERAGES CERTIFICATE NUMBERAU 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 SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTRINSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE ( J OCCUR PREMISES a occu RENTED $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) A ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS X AUTOS AU2017TLP04101 7/3/2017 7/3/2018 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ 25,000 _ HIRED AUTOS AUTOS (Per accident) -. Underinsured motorist BI split $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER I ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 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 T Reid Woods/REID ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSO25 roniem/ WAmijonlialnliGID • N DRIVER LICENSE 4aucuFOSTEKR313D8 9cuass +FOSTER 2KELLY RAY 3 Dos 03/28/1969 4a!Gs 12/08/2017 s 35611 SR 507 UNIT C MCKENNA WA 98558 2•M 15 SEX M is EYES BRO 16 HGT 6'-04" 17 WGT 300 - 12 RESTRICTIONNO 9a END B 4b EXP 03• - *- S��� 5DD FOSTEK,R31 17342411109 REV 01/06!2015 dIWASHINGTON STATE DEPARTMENT OF CERTIFIED ss LICENSING Driving Record - FOSTEKR313D8 Abstract of 3 Year Driving Record-Non-commercial This information is current as of 1/16/2018 8:39:56 AM Driver info ation Driver license status PIC FOSTE-KR-313D8 Status Clear Last FOSTER Suffix Issued 12/8/2017 First KELLY DOB 3/28/1969 Expires 3/28/2023 Middle RAY Gender Male Original issue date 7/12/1994 Restrictions PDL B 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 A %ASHINGTON ST:TE DEPARTMENT OT LICENSING Registration Certificate Model Year' Make Model Body Style Vehicle identification number(VIN) Scale Weight 2003 MERC SABLE SedanA 1 MEFM50U33G632953 3,202 Plate/Tag no Tab/Decal no Primary vehicle use type Issue date Exp date ', ,� .!, I1 J1 ,,i ,, BBN2259 W762185 Taxi Cab 06/30/2017 06/23/2018 ' IT''��l ti '�'� ' , ''.110!'(it I di'I Ili, �''' i,,),yi, i: ,1' '4 r 1i !.N'll [Plate/Tag no Tab/Decal No Vehicle use type Issue date Exp date lid, 1t' ,�i i � fii uldi i I i ! 1i Al, 1 „g!' Gross Weight Gr wt start date Gross weight exp date Fleet no Equip no ' 'II t " ' 4y11 '14.1 'n1 113' 1 11. I . 1 lit i t,.N l i i ' Registered Owner Legal Owner FOSTER, KELLY Same as Registered Owner DBA KELLY CAB PO BOX 1214 YELM WA 98597-1214 Brands/Comments: 21180/2003, GOLD, Use Tax Waived-Gift, Display tab on back license plate only-front plate is still required, WA !Former Rental f i 1 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 pers. or persons set forth as legal owners. WISP X i X \ a/LiCett i Signature of registered caner Signature of registered owner Date and place signed Date and place signed L0017540928 •:x-420-802 iR 12.16:Page'of 2 Vehicle Information: BBN2259 1MEFM50U33G632953 2003 MERC SABLE Sedan Filing Title Filing $4.00 Service Title Service Fee $12.00 Title Vehicle Title Application S15.00 Emergency Meoical Services $6.50 Fee Total: $37.50 Issue Date: 06/30/2017 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