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TIM DUSSETSCHLEGER - EXP 12/2018 City of ye Cm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Tumwater, and Lacey. DNew Permit ❑Renewal (Permit# —11 3�� ) 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) gFor-Hire Driver ❑Locksmith OSolicitor APPLICANT INFORMATION *Full Legal Name: (F/M/L)Tir4Ahy I01 Ut �M P4-4-SJe_tc--H ,,E►�Q„� Other Name(s) Used: (If additional space is needed, use the back of this page) (F/M/L) (F/M/L) 7 – 85 *A Sex/14 *Date of Birth 11 -2 19 *Age 3�' SS# 6° 7`s - � *Height S '7 *weight 7-SO *Hair Color I Ro *Eye Color 2 Place of Birth Have you ever had an occupational permit suspended or revoked? ❑Yes LJNo If, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for your street address, please) *Street Z-1— / 14 V I - Ct pl 6 t *City / M *State V 4 *ZIP 7$,597 *Phone Cell 2-45g- 466 - 3736 *Mailing address (❑same P" 0,,/ ist ytM) Itis 755 5 /7 *email ` IMM / v At-117 hat -Lor► 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 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 tA14) Date ❑ 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 ID Denied Reason: ❑Incomplete application ❑Criminal record ❑Prior permit revocation ❑False information ❑05.03.060 ❑Other (specify) ❑Fees paid: Permit# ❑Base fee refunded: Date El Permit ID completed ❑Applicant notified By Date IE Permit fee only (non-fingerprint renewal) Page 9 of 9 DATE(MM10t1,YYYV) 1 ACG II CERTIFICATE OF LIABILITY INSURANCE 6E27�zo17 J ITHIS 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 1 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED IREPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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). CONTACT PRODUCER 1 ONES: Timothy Reld Woods HUMBLE & DAVENPORT INS BROKERS INC PHONE (425)226-8221 FAX (425)255-9342 (425)255-9342 �_LAX.No.t.ldl:--------- — E-YAIL reid@humbledavenport.com 3500 Maple Valley Hwy 1AgDAg...ft_ _ --- _ _ __ INSWIER(E)AFPOR01NOCOVERAGE � NAIC f Renton WA 98058 i INSURER A New York Marina t General-Ins Go j 16608 INSURED 1400J2ER S:.�.- ._.�,.. - 1 Kelly Ray Foster, DBA: Kelly Kab IkQUR[ C_ — -------r- — IPO BOX 1214WSUR 0.—_—_------------4.---^- INSURER E: I Yelm WA 98597 IN RERF: COVERAGES CERTIFICATE NUMBER. U 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. Istaia -___ - '—_- --_._-- LI—.._...___�� ;—___.._. "pOUCV EFF I--POLICY EXP-' LIMITS L TR LTR; TYPE OF INSURANCE �INBD"NCI; POLICY{CY hYlY6ER �YMIDOlYY'A'J;(MMIDDIVYVYI- COMMERCIAL GENERAL. ABILITY EACH OCCURRENCE3 aoEfO1 N?E0_` CLAIMS-MADE i—J S OCCUR 1 PREMISF.� t9c5A ML--X ! MEP EXP(Any one person) 3 -' , -. PERSONAL a Atm iNJuRY 3 I I '— ._ GENERAL AGGREGATE 3 1 POLICY L !AWL L AGGREGATE UMIT APPLIES PER: ( I I'_;JE pR J LOC , PRODUCTS-COMPIOP AGG 3 - — i ---.- - --�3 OTHER •••',-Y"" E L MI AUTOMOOLLE UAI(UTY j i -1 4.1 W M �-Y s---- - --- -----�qNY AUTO ; i ODDLY INJURY(Per person) 3 A 1.----1 AUTOS ED Fiji ED LEC i I i 7W2017TW04101 7/3/2017 7/3/2019 BODILY INJURY(PeracridaM) $ t�1 OPERTI ) S 25.000 1^'" HIRED AUTOS AUTNONQSWNED O�eracoidsM I matafnt ll Edit 3 100,000 j UMBRELLA LIAB OCCUR I I EACH OCCURRENCE S ____ _� Y""J EXCESSUA° LAIMS-ASAD04 I _AGGREGATE - r .P-,_ . _ _ DEO R,TENTI.. i .- - , WORKERS COMPENSATION j _1.-e9TStT-g-:,.—j -- ANYEMPLOYERS'LIABILITY YIN' I (E.L.EgCH A,C(,IDENT S ANY PROPR:ETOR*PARTNERIEXECUTIVE 11 OFFICER/MEMBER EXCLUDED' : NIA P III E.L DISEASE-EA EMPLOYEE'S IMandHory In NH) I I b d=wme unda� +j ( ' .E.L DISEASE-POUCY UMIT•5 aGE$CRIPTIori O<OPERATIONS W.ow -- r------ I. i i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Add/Vona:Rema.As 5c uduI,may Le anaci,ad If more space m requ rod) EVIDENCE OF INSURANCE 2003 Mercury Sable 4l1MRFM50U83G626324 „.........._ ........________ _ ._____, CERTIFICATE HOLDER CANCELLATION (360)705-6699 £orhire@dol.wa.gov SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Washin ton De arunent o£ Licensing THE EXPIRATION DATE THEREOF, NOTICE WILL BEDELIVERED IN 9 P ACCORDANCE WITH THE POLICY PROVISIONS. For Hire Program I PO Box 4039I AUTHORIZED REPRESENTATIVE Olympia, WA 98507-9039 CIL Re 1 J Woods/RE:T.I:, ------ --'''" • ^`"*---'-'"--"----.- "- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and iogo are registered marks of ACORD INS02519(1I4fi. • LICENSING Registration Certificate Model Year Make Model Body Style Vehicle identification number(VIN) Scale Weight -2003 MERC SABLE Sedan 1MEFM50U33G632953 3,202 Plate/Tag no Tab/Decal no Primary vehicle use type Issue date Exp date rmBBN2259 W762185 Taxi Cab 06/30/2017 06/23/2018 )l� i ' i• I'� PIErte'Tag no Tab No Vehicle use type Issue date Exp date 4 � " t,1' ' .t loll Gross Weight Gr wt start date Gross weight exp date Fleet no Equipno 1'I',I VA"'1'!i'.111Ir 1J1141I.?II Registered Owner Legal Owner FOSTER. KELLY Same as Registered Owner DBA KELLY CAB PO BOX 1214 YELNt WA 98597-1214 Brands/Comments: 13012003. GOLD Use Tax Waived-Gift, Display lab on back license plate only - front plate is stili required, WA 'Fn mor Rental 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 persgr, or persons set forth as legal owners. X 7-77 f X 1 1& 1 �" 1r Signature of reg ste/ed Owner Signature of registered owner Date and place signed Date and place signed L0017540928 Vehicle Information. t3BN2259 1MEFM50U33G632953 2003 MERC SABLE Sedan F.1nG Tdie Fnma S4 00 Se'e.ce `.ate Service Fee S12 00 !e Venicle T lie Application S15.00 Emergency Meccas Services 56 50 Fee Total: 537.50 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 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. El Submit a copy of your driver's license or, if no current driver's license, your State-issued ID card. El Provide an ID photo. El Have your fingerprints taken at YPD. ❑ Submit a copy of your complete driving record (for-hire driver/operator applicants only). El Submit your completed and signed application form. El Pay your fees (cash, check or debit card). Page 8of9 L i 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 Business Owner/CEO ❑ 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 N� 1 Any felony V 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