LINDA LARSON - EXP 12/2018 1qCq)
City of yet3n 18
OCCUPATIONAL PERMIT APPLICATION
Permits issued by the City of Yelm are valid in Yelm, Olympia, Turnwater, and Lacey.
ew Permit L1Renew (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) -:or-filre Dover DLocksmith DSolicitor
APPLICANT INFORMATION -
*Full Legal Name:
) L. OR s t
Other Name(s) Used: (If additional space is needed, use the back of this page)
(F/M/L) • A
4 C
(F/M/L)
Sex c- *Date cf Birth *Age .2() SS# 7;-- 1
"Height lWeight )-01) *Hair Color • 1 1 Tye Color (Lei
Place of Birth iv
Hove you ever had an occupational permit suspended or revoked? EIYes 4No
If, "yes," when and where__
HOME ADDRESS (Do not use a P.O Box for your street eddn9ss,please)
I A 4
—
'Street • r ,0 j 'City ' *State
*ZIP g CSq 1 *Phone
'Mailing address ( me
.
n 1 1 I azio
7: 341, Page 5 of 9
. ,
OTHER RECISIDNES
_
List all other states and cities where you have lived in the past five (5) years.
, .
i -7-- From To
____271 State I City ,
1 (month/year) (month/year)
I I
----
i 4
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BUSINESS INFORMATION One business Alt is iliit3tOO to ttl$4 permit)
*Business Name 4,1_,L I _a . # —
Business Owner/CEO i _1 1 j —......, D Applicant
........
//..
Street ).J - i ,/e_ city44rini. StateALLt
° ,i9e3 Cell _
Email , Yelm Business License# _
I Ilip Elv_EL_DYLKEI riTi-ASJPRY
including your current employment, list the jobs you've held during the past five (5) years.
1 Job Title_4___ Ern_p_toier 1____.____S_V_State FrOm/To '
' 1 i
'1-2 1 1
7. ..
I 4.1._
5 , I
*CRIMINAL HISTORY(sett-diwo.3:00
In the past five (5) years, have you been convicted of any of the following offenses')
— _
i Offense_Type_,,,, _ Yee No 1
A
2 'lar_seltyltefiAohicle plowlir9
..,. ._
r-i—bc;mestic violence
4 Fraud/Identity theft
r 6 iAnydrugrelatedCiite
l
6 Any sex offense
I An crim.,...eist children or vulnerable adults A
4 '
Page 6 of 9
4
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 PERM!T 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 tine back of this form for additional vehicles, it
necessary)
� ,.�,.�. Vehicle �.�.•.,- Vehicle 2
Year ._ . -- ...
Maks
Model
Cole
t
Vehie e) Yetit 4 I
X
Make
w_.._..
Model
Color
—Plate* I
State t
Owner
_ _ a _ _ _
Page 7 of 9
SUPPLEMENTAL INFORMATION — FOR-HIRE DRIVER PERMIT APPLICANTS ONLY
YMC 05.03.030 Qualifications (self disclosure)
Now
Qualification Yes No
h./ 1 Have you had a valid Driver's License for the past two years?
If yes, in what state(s)? •
la
2 Are you 18 years old?
3 Do ou have any physical or mental infirmities that may affect your drivin.? ****111
Have you been convicted of three (3) ormoremoving violations during any one
4
I (1) year period in the past five (5) years?
5 i In the past five (5) years, have you been convicted of operating a motor vehicle
while under the influence of alcohol or drugs? _
6 I 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 drLigs?
7 In the past five (5) years, have you been convicted of negligent driving or
reckless operation of a motor vehicle?
In the past five (5) years, have you been convicted of vehicular homicide or
I_ 8_I assault with a motor vehicle?
"All 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.
O Submit a copy of your driver's license or, ;f no current driver's license, your State-issued ID card.
O Provide an ID photo.
0 Have your fingerprints taken at YPD.
O Submit a copy of your complete driving record (for-hire driver/operator applicants only).
O Submit your completed and signed application form.
O Pay your fees (cash, check or debit card).
El
Page 8 of 9
•
CER7lFICAT1QN
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 -n occupational ermit issued under YMC 5.03, and I hereby consent to such checks.
� `- �.
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Signature, Date
�
O I request a copy of the criminal history data used to determine my fitness for a permit.
City use only below this line
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Date Received Reviewed By. ,` 1� "''` Review Date_
pproved C.lDenied Reason: Dlncomplete application ❑Criminal record
LDPriar permit revocation GFalse information
D05.03.06C ❑Other(specify)
�. CJFaes paid: Pemuit# 1% " OO\ ri Base fee refunded; Date_____
Permit ID completedjiATiplicant notified By 4' 10,32 Date 1 lel
0Permit fee only (non-fingerprint renewal)
Page 9 of 9
•
diti►SNiNETON STAtt UPROOT Uf
m 1..ICENSING Registration Certificate
Model Year'Make Model — Body tyle 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 t'' • a .� t is i LI It4
BCI-16873 W622597 Taxi Cab 41/0612017 01/06/2018 t 0 ' °411 , y i'-hll i'
Plate/Tag no Tab/Decal No Vehicle use type Issue date xp 5, 1t. i! it T°+> !tl 1r1
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Gross Weight Gr wt start date Gross weight exp date fleet no I Equip no I, is
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Registered Owner Legal Owner
KELLY R FOSTER DBA KELLY i AB Same as Registered Owner
PO BOX 1761
YELM WA 98597-1 76 1
[Brands/Com-merits: 2460/2003,GREEN,t3isplay bon hack 1"tcense plate only-front plate is still required,WA Prior Taxi,WA Other y
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 cit other security interest of
any person exce't the person or persons set forth as legal owners.
Signature of registered owner Signature of registered vwmer
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Dews/xi piece signed data and piece signed
W001178 2$
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syJ s,72(8714,115)Rage i rot
Vehicle information: t3CH6673 1ttt1EFM50U8 326324 2€303 MERC SAKE Sedan
Filing Kegs-Nation Filing g3.09
Tit:e Filing $4.00
PIely Piste t$e{!sobvtty 54.30
Oremet taus Ptsar U0.00
Revttration Ragstratton Usletttie $3000
Lief se MAW Tai iina y SO 25
Doi*of L tent lg Sotocst 30.50
Veitrete weight $25.00
jeNirq Tine Servlet.Fac $12.00
Tile time/slew/A dkitc..I Se•Mricos St.50
Venlcie Tide AorYication $15-00
Pea Tote:: $12 .2
You can get a copy of this cash/fee receipt detail at www,uoi.wa.gov.
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4.01:7--‘--°4634' aRrArCERTIFICATE OF LIABILITY INSURANCE DAfE(MAUDDreYYY)
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
AIM., REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
I PQ' ANT: if the certHfcs%holder Is an ADDmONAL I SU--`0,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require en endorsement A 5httement on this certificate does not confer rights to the
certificate holder in lieu of such endoraement(s).
PRODUCER I Igoe: Timothy Raid Woods
YTUI.031,2 & DAVENPORT INS gRpZggg INC I.PHONE (425)226^8221 i INC.Nol:(«5)855-93a2
3500 Maple Valley Hwy 1!:0416.:7aid9humb1ad*v®espart.nom
_1$84REWa)AriPoR4set CoveRAr NMC a
Beaton WA 98058 ikgrAgs&Ott_Cs, Mg a,me b GlwaerAk JAL co 16608
INSURED ' U $" ,---,-._ ,
Kelly gay Foster, AHA: IIsilly *MRD ..II a.S.:. .,
Tells WA 90597 II trr R f%:
COVERAGES CERTIFICATE NUMBERAU REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY SE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS:
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES..LIMITS SHOWN MAY HAVE BEEN REDUCED
pFBY PAID CLAIMS. ,
1 TYPE OF INSURANCE IN$P-lnrP POLI 'Nok a _ fMreabDrWKYI i iMAM,�PNYYYIT^ LIMITS . _ .
COMMERCIAL.a5NERAL LUAair TTEACH OCCURRENCE_ $
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MEDEX�My ono pataert] S
ri60NAL i FOv INJURY i
OEN'L AGGREGATE�`^ LIMIT APPLIES PER; i I GENERAL AGGREGATE $
� 1 POLICY 2 LOC j PRODUCTS-COMP/OF AGO $ •
OTHER: �^. I s
AUTOMOBILE LIA9(LrTY •9;311 s,
^"-II ANY AUTO I I BODILY INJURY(PKpr son) $
1 ALL OrN IED AO DULED
AUTOS Ati2@17ES 1*f1w]3@i T/3fao17 7/3/8@1S S09iLY INJURY(PwerrideM) 8
N R tPER1Y' MA9�e"- & 28,000
(E31 e
_�HIRED AUTCO AUTOS y i m.,,--etEI< t $ 100,000
, I UMBRELLA L,IAB II=UN 6LA^N a____95.,:__URB NctS.. >. 1 S
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f" II ; i(" AiBLiiA$4�k=P$ -- 3
n tory In hii)) r ,CREASE-EA EMPLOYE $
..IFTI NV(ItBfiRAT19NS . I OLICY LIMIT 13
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES Meant)101,Addticoul iroroaekx UhAlt.116,may 14o attoolisd if mew OW,Is Fsquirsd)
EVIDSNCE O8' /NSLTAANCIE
2003 t6>a oury Sable * VM50US30526 324
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CERTIFICCATE 1..,1?EFt
CANCEL. 'TI•N _ ... _ ...
x(3601 705-6699 f Orhirea col.sea.gay SHOULD ANY OP THE ABOVE DESCRIBED POLICIES 88 CANCELLED BEFORE
tOfs Department at Za c�rsSi.. THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
Wi6k�l:1
Q pB ACCORDANCE WIN THE POLICY PROVISIONS,
Tor Faire Program -
PC Bois 9039
Olympia, WA 98507-9039 I AUTHGMti2EDRRPR.F.SENTA1Wt
I
lay :' teid Woods/REID
f] 90; 2014A •'D CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD Remo and logo are rogietorati marl*of ACORD
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dtWASHINGTON STATE DEPARTMENT OF CERTIFIED
LICENSING Driving Record - LARSOLJ336B5
Abstract of Driving Record-Employment
This information is current as of 11/3/2017 4:55:37 PM
Driver information Driver license status
PIC LARSO LJ 33685 Status Clear
Last LARSON Suffix Issued 2/1/2014
First LINDA DOB 1/25/1967 Expires 1/25/2019
Middle JOANNA Gender Female Original issue date 3/7/2000
Drive record history
Action Eligibility Release Violation DUI/BAC Licensing
date Reason Action taken date date date Violation# detail THC state
4/21/2008 Failure to make required payment of fine and costs Released 4/21/2008 2/7/2018 104888656
3/28/2008 Failure to make required payment of fine and costs Suspended 3/30/2008 2/7/2018 104888656
Comments
Date Comment
11/23/1998 Moved out of state to DE1. Returned to WA on 3/7/2000
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
t
TYPE OF TRANSACTION: NFUF
DATE TRANSACTION INITIATED: 01/05/2018
TRANSACTION CONTROL NUMBER: WA4099300008677699
NAME: LARSON,LINDA JOANNA
EMPLOYER AND ADDRESS: WA920676Z
NON FEDERAL USER FEE ELECTRONIC RESPONSE
YELM ORDINANCE 5.03.045 RCW 35.21.920
SEARCH PARAMETERS:
NAME: LARSON,LINDA JOANNA DOB 01/25/1967
AKA: GIEZENTANNEO,LINDA J
SEX F RAC W
SEARCH MODE: Conviction
WA920676Z YELM POLICE DEPARTMENT DATE PROCESSED 01/08/2018
YELM, WA
PROCESSED BY: 13
PURSUANT TO PURPOSE OF INQUIRY, NO RECORD FOUND
01/08/2018
CRIMINAL RECORDS DIVISION
WASHINGTON STATE PATROL
WA920676Z
YELM POLICE DEPARTMENT
206 MCKENZIE AVE SE
0 YELM, WA 98597
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