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WAYNE ROCHA - EXP 12/2019 City of yeCm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of YeIm are valid in Ye/m, Olympia, Turn water and Lacey. El New Permit gRenewal (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) OF-or-Hire Driver E Locksmith CII.Solititor APPLICANT INFORMATION *Full Legal Name: (F/M/L) 4)(11,411-e LearJtro Zo4v,_ Other Name(s) Used: (if additional space is needed, use the back of this page) (F/M/L) (F/M/L) Sex/V? *Date of Birth (a-23\—484 *Age SS#531E16 ev *Height *VVeight *Hair Color *Eye Color Place of Birth ALK.:/c.‘, W.% Have you ever had an occupational permit suspended or revoked? CiYes No If, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for your street address, please) *Street 1-16CYTh 22,4 cl"-/Q *City 1---act- *State *ZIP Ofc (o03 *Phone 16O c1-0(c) f-(652- Cell -Mailing address Game *email RQC,k0,2- 100 Lkie roA" Page 5 of 9 OTHER RECENT RESIDENCES List all other states and cities where you have lived in the past five (5) years. State F7- City From To (month/year) (month/year) 1 RcA:t ;eir 2 3 5 BUSINESS INFORMATION (the business that is related to this permit) *Business Name Ki( Wite Business Owner/CEO Applicant Seei 27,-Z e qa, 14-t,c- City 16-e(ilv\ Stat4A-14 ZIPn Phone e().. q k ce-s Cell .A30 Emailei\ilt,SCV-IcM,Cilito,Ccirvt YeIm Business License# -1.07-3q1 EMPLOYMENT HISTORY Including your current employment, list the jobs you've held during the past ye (5) years. Job Title Employer City/State From/To1 , 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 Larcen /theft/vehicle •rowlin• —3 Domestic violence 4 Fraud/Identity theft 5 1 Any drug-related crime 6 Any sex offense 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 P-rmit, complete the appropriate Supplemental Information section that ft Vows. For any other type of permit, skip to the "Application Document Checklist" section. SUPPLEMENTAL INFORMATION — SOLICITOR PERMIT APPLICANTS 0 LY 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 his form for additional vehicles, if necessel),) Vehicle 1 Vehi le 2 zoE)- i Make kvivIc9,A Model c_33\1\ Color SOO Plate* kC -T3 State Owner I ,Lia. 160 KiAiikcat,-,_ a! Vehicle 3 Veh cle 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 Nol Have you had a valid Driver's License for the past two years? 1 a If yes, in wthastate(s)? coa r\trx, NcYr• 2 Are you 18 years old? 3 Do you have any physical or mental infirmities that may affect your driving? Have you been convicted of three (3) or more moving violations during any one 4 >C. (1) year period in the past five (5) years? ; In the past five (5) years, have you been convicted of operating a moto 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? In the past five (5) years, have you been convicted of negligent driving pr 7 [ reckless operation of a motor vehicle? 8 I in the past five (5) years, have you been convicted of vehicular homicide or I ,/ assault with a motor vehicle? Y\ *All applicants must complete this section APPLICATION DOCUMENT CHECKLIST You need to do the following things before your application will be procelsed. Use this checklist to make sure you have all the materials you need. CI 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. LII Have your fingerprints taken at YPD. El Submit a copy of your complete driving record (for-hire driver/operator applicants only). CI 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, 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 5,0 n-r_ Date H \ lie 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 ODenied Reason: ElIncomplete application EiCriminal record OPrior permit revocation EiFal e information C05,03.060 CiOther (specify) DFees paid: Permit# EBase fee refunded Date OPermit ID completed ElApplicant notified By Date OPermit fee only (non-fingerprint renewal) Page 9 of 9 tASH3ii;f CZ LICENSING Registration Certificate Model Year Make Model Body Style Vehicle identification number(VIN) Scale Weight 2002 HOND ODYSSEY Passenger Van .2HKRL18962H528929 4,387 Plate Tag no Tab/Decal no Primary vehicle use type issue date Exp date "). • BKM6093 C415500 For Hire 05/29/2018 05/11/2019 1Plate/Tag no Tab/Decal No Vehicle use type • Issue date Exp date GI;ross Weight Gr wt start date Gross weight exp date Fleet no Equip no 444 .4! F ' p I`110i1 1114 1.04.1 4. *. ; • ti••• . i Registered Owner Legal Cwner FOSTER, KELLY SIMMONS, RICHARD DBA KELLY KAB PO BOX 2703 PO BOX 1214 YELM WA 98597-2703 YELM WA 98597-1214 'Brands/Comments: 28250/2002, GOLD, Display tab on back license plate only-front plate is still required 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 Date and place signed Date and place signed L0040237592 Vehicle Information: BKM6093 2HKRL18962H528929 2002 HOND ODYSSEY Passenger Van Filing Registration Filing $3,on Other Duplicate Registration $1.25 Registration Dept.of Licensing Service $0.50 License Plate Technology $0.25 Service Registration Service Fee $5.00 Fee Total; $10.00 Issue Date: 07/06/2018 You can get a copy of this cash/fee receipt detail at www.dpl.wa.goy. Skip a trip-go online www.dol.wa.gov A�+r � CERTIFICATE OF LIABILITY INSURANC r DA, ,MMroD.YY�Y' 07103/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TH CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE A. FORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUI G INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL IN-URED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require n endorsement- A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Deshonda Shubin PRODUCER NAME: HUMBLE&DAVENPORT INS BROKERS INC (Aio,Nc,Ext): (425)226-8221 FAC,No): (425)255-9342 3500 Maple Valley Hwy a DRESS: DeshondaSlhumbleda, nport.com INSURER(S)AFFOR I,ING COVERAGE NAIC# Renton WA 98058 INSURER A: New York Marine&Ge -ral Ins Co 16608 INSURED INSURER 8: Kelly Ray Foster INSURER C; dba Kelly Kab INSURER D: PO BOX 1214 INSURER E: Yelm WA 98597 INSURER F: COVERAGES CERTIFICATE NUMBER: CL187321432 'EVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A:OVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT TH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS S`BJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TNSR ADDLSUMR POLICY EFF POLICY EXP UMITS LTR TYPE OF INSURANCE INSD wvo POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES{Ea occurrence) $ MEG EXP(Any one person) 5 PERSONAL&ADV INJURY 5 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY ECT LOC PRODUCTS-COMP/OP AGG S OTHER _ -AUTOMOBILE LIABILITY (ECO aB ccagDtSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) 5 100.000 A OWNED X SCHEDULED AU2018TLP04101 07103(2018 07103/2019 BODILY INJURY(Per accident) s 300,000 AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED $ 25.000 AUTOS ONLY AUTOS ONLY (Per accident! Underinsured motorist 81 s 25/50 UMBRELLA GAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE r S I DED RETENTION $ _ $ WORKERS COMPENSATION PSEATUTE ERH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE N IA El EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ i If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below I DESCRIPTION OF OPERATIONS)LOCATIONS J VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required 2002 Honda Odyssey 2HKRL18962H528929 CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE D SCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERE F,NOTICE WILL BE DELIVERED IN Washington Department of Licensing For Hire Program ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 9039 AUTHORIZED REPRESENTATIVE Olympia WA 98507-9039 ', *lk,U +,1)yam) I ©1980-201 ACORD CORPORATION. All rights reserved, ACORD 25(2016(03) The ACORD name and logo are registered marks of ACORD Background Check ❑ References, Resume, Lease Application ❑ Drivers Abstract (Non-Commercial)—3 Yr. ($13) Passport Pictures&Finger Print Card City of Yelm ❑ Pictures—Wal-Mart or Rite Aide($20) You will need 3 photos for the Ci y of Yelm O Fingerprints—($19) 3000 Pacific Avenue Southeast,Olympia ❑ For Hire Application, Background Check($70) ❑ Registration Liability Insurance ❑ Driver's License ❑ Make a copy of your application for my files Washington State Master Application(UBI)($20) Pierce County(Coming Soon) ❑ For Hire Application authorized by KellyKab ❑ 2401 South 35th St,STE 200, Tacoma, 98409 O Jill Munns @ 253-798-2123 O Application for Occupational License($30)Registration ❑ Liability Insurance ❑ Money Order finger printing @ County City Bldg. in Tacoma ($30)Drive `s License ❑ 4 photos Administrative Policies ❑ W-9 ❑ Lease Agreement ❑ Company Policies Manual ❑ Check Driving and Cell Phone Qualification ❑ Copy of Driver's License for company file ❑ Copy of Social Security Card for company file ❑ 1 Picture for company file ❑ Copy of City of Yelm paperwork for company file O Damage Deposit Schedule W-9 Request for Taxpayer Give Form to the Form requester.Do not (Rev.August 2013) Identification Number and Certification: send to the IRS.Department of the Treasury Internal Revenue Service Name`/'(^�a's`J�si�wn�on your income tax return) Business name/disregarded entity name,if different from above N 0 a Exemptions(see instructions): c Check appropriate box for federal tax classification: ° 0individuallsole proprietor El Corporation El Corporation El Partnership Trust/estate Ei c o Exempt payee code(if any) a u ❑ Limited liability company.Enter the tax classification(CeC corporation,S=S corporation,P=partnership)► Exemption from FATCA reporting o code(if any) c N C E. 0 ❑ Other(see instructions)b.Ic o Address(number,street,and apt.or suite no.) Requesters name and address(optional) a y5 fl' ' c sr City,state,and ZIP code °' Lu.c Cf, t,3, l'FID°3 List accouok number(s)here(optional) Part I Taxpayer Identification Number(TIN) l S�ucial security number �__� Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line J to avoid backup withholding.For individuals,this is your social security number(SSN). However,for a f 2 p — q 3 c� / resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other `� lU entities,it is your employer identification number(EIN).If you do not have a number,see How to get a 1 TIN on page 3. f?nployer identification number Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose number to enter. IMB Certification Under penalties of perjury,I certify that: 1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and 2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividen is,or(c)the IRS has notified me that I am no longer subject to backup withholding,and 3. I am a U.S.citizen or other U.S.person(defined below),and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is corre;t. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you art currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,acquisition or abandonment of secured property.cancellation of debt,contributions to an indiv dual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you'lust provide your correct TIN.See the instructions on page 3. Sign Signature ofI '1.2-0 �' Here U.S.person h*k.,JCil 14- J;� C L Date I* 1 q General Instructions) withholding tax on foreign partner;'share of effectively connected income,and 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are Section references are to the Internal Revenue Code unless otherwise noted. exempt from the FATCA reporting,is correct. Future developments.The IRS has created a page on IRS.gov for information Note.It you are a U.S.person an a requester gives you a form other than Form about Form W-9,at www.irs.gov/w9.Information about any future developments W-g to request your TIN,you mu use the requester's form if it is substantially affecting Form W-9(such as legislation enacted after we release it)will be posted similar to this Form W-9. on that page, Definition of a U.S.person.For .deral tax purposes,you are considered a U.S. Purpose of Form person if you are: •An individual who is a U.S.citiz n or U.S.resident alien, A person who is required to file an information return with the IRS must obtain your corporation, or association created or organized in the correct taxpayer identification number(TIN)to report,for example,income paid to •A partnership, con any, you,payments made to you in settlement of payment card and third party network United States or under the laws the United States, transactions,real estate transactions,mortgage interest you paid,acquisition or •An estate(other than a foreign f state),or abandonment of secured property,cancellation of debt,or contributions you made •A domestic trust(as defined in tiegulations section 301.7701-7). to an IRA. Special rules for partnerships,i'artnerships that conduct a trade or business in Use Form W-9 only if you are a U.S.person it(the a resident alien),, tthe United States are generally required to pay a withholding tax under section provide your correct TIN to the person requesting it(the requester)and,when 1446 on any foreign partners'share of effectively connected taxable income from applicable,to: such business.Further.in certair cases where a Form W-9 has not been received, 1.Certify that the TIN you are giving is correct(or you are waiting for a number the rules under section 1446 require a partnership to presume that a partner is a to be issued), foreign person,and pay the section 1446 withholding tax.Therefore,if you are a 2.Certify that you are not subject to backup withholding,or U.S.person that is a partner in a partnership conducting a trade or business in the United States,provide Form W-r to the partnership to establish your U.S.status 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If and avoid section 1446 withhold rig on your share of partnership income. applicable,you are also certifying that as a U.S.person,your allocable share of any partnership income from a U.S.trade or business is not subject to the Cat.No.10231X Form W-9(Rev.6-2013)