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KELLY FOSTER - EXP 12/2019 City of yeCm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Tumwater, and Lacey. DNew Permit VRenewal (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) t For-Hire Driver 0 Locksmith 0 Solicitor APPLICANT INFORMATION *Full Legal Name: (F/M/L) 16e`V, .cf"4 6- Other Name(s) Used: (If additional space is needed, use the back of this page) (F/MIL) (F/M/L) Sex10 *Date of Birth ?-A-21c—t1f *Age -lam SS# t9-k7' " t 17— *Height LI `.J *Weight *Hair Color Q--110 `Eye Color Place of Birth Have you ever had an occupational permit suspended or revoked? DYes (rjNo If, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for your street address,please) *Street 55-Lotl ' C LVM I f G *City fry kC et- *State1,04 *ZIPc 3' *Phone Cell *Mailing address (Dsame -FO x Y2,W& VSe h P114-ct 96A *email\ vn ftec 3y776:44, co-vr, Page 5 of 9 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) i2 3 4 fi 5 BUSINESS INFORMATION (the business that is related to this permit) *Business Name Kc tVlib Business Owner/CEOa\\%-\Q,"''0;4- 0 Applicant Street Z22- qt.,\NY 'kW City 16-c(t" Stat ZIPC� Phone -X11-ICZS Cell I `lciZS" Email KeAttf_k-r.I.‘44).01CrArt YeIm Business License# EMPLOYMENT HISTORY Including your current employment, list the jobs you've held during the past f ve (5) years. �u Job Title Employer City/Slate From/To I i l� 4{ 1/1\)ezt rr2 M- I i f rae 3t 5 . *CRIMINAL HISTORY (Self-disclosure) In the past five (5) years, have you been convicted of any of the following of enses? 1 No Offense Type Yes i Any felony ± 2 Larceny/theft/vehicle prowling 3 Domestic violence 4 Fraud/Identity theft e 5 Any drug-related crime 6 Any sex offense 7 1 Any crime against children or vulnerable adults Page 6of9 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. —3\-00.1 i I)1 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 ZCV Make k e Model \ise'zF,v) _ 1 Color SOOk Plate# (bar\ ( ,( 3 State LPA Owner yu_kk D3► c<stAgivzi 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 I Yes No 1 1 Have you had a valid Driver's License for the past two years? ✓ I 1a If yes, in what state(s)? 2 Are you 18 years old? l/ 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? t 5 In the past five (5) years, have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs? in the past five (5) years, have you been convicted of having physical control of 6 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 Dr { reckless operation of a motor vehicle? 8 I In the past five (5)years, have you been convicted of vehicular homicide or 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. { { ❑ 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. ❑ Submit a copy of your complete driving record (for-hire driver/operator applicants only). ❑ Submit your completed and signed application form. ❑ 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 tie City of Yeim 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 • � Date I ZS- fl d 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 ❑Denied Reason: ❑Incomplete application DCrirhinal record ❑Prior permit revocation ❑False information 005.03.060 ❑Other(specify) D Fees paid: Permit# D Base fee refunded: Date ❑Permit ID completed ❑Applicant notified By Date ❑Permit fee only (non-fingerprint renewal) Page 9 of 9 ACO CERTIFICATE OF LIABILITY INSURANC DATE(MM/DDIYYYY) 07/03/2018 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 INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(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 PHONE (425)226-8221 FAX NM: (425)255-9342 (AtC,No,Est): I 3500 Maple Valley Hwy AE-MAIL D•DARESS: DeshondaSIhumbleda port.Corn INSURER(S)AFFO ING COVERAGE NAIC R Renton WA 98058 INSURER A: New York Marine&Ge ral Ins Co 16608 INSURED INSURER B: Kelly Ray Foster INSURER C: dba Kelly Kab INSURER 0: PO BOX 1214 INSURER E: Yeim WA 98597 INSURER F: COVERAGES CERTIFICATE NUMBER: CL187321432 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. ' CY EFF POLICY EXP L ADDLStJVO POLICY NUMBER (MSM DO/YYYY) (MM/DO �') LIMITS TYPE OF INSURANCE INSD WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED ICLAIMS-MADE OCCUR PREMISES(Ea occurrence) Sr MED EXP(Any one person) 3 PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE S POLICY {ECOT- LOC •PRODUCTS-COMP/OP AGG ,--- OTHER: $ OTHER: COMBINED SINGLE LIMIT $$ AUTOMOBILE LIABILITY (Ea BINE n) ANY AUTO BODILY INJURY(Per person) $ 100,000 A — OWNED XSCHEDULED AU2018TLP04101 07/03/2018 07/03/2019 BODILY INJURY(Per acudent) S 300,000 AUTOS ONLY , AUTOS HIRED - NON-OWNED PRO(PerPROPERTY PERTY DAMAGE $ 25,000 accident) _ AUTOS ONLY _ AUTOS ONLY Underinsured motorist 81 $ 25/50 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ 1 $ WORKERS COMPENSATION PER UTE ERH AND EMPLOYERS'LIABILITY Y!N ANY PROPRIETOR/PARTNER/EXECUTIVE 1 ! El EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE 3 II yes,describe unoer E.L.DISEASE•POLICY LIMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION Of OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space is required) 2002 Honda Odyssey 2HKRL18962H528929 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Washington Department of Licensing For Hire Program ACCORDANCE WITH THE POLICY PROVISIONS, PO Box 9039 AUTHORIZED REPRESENTATIVE ry Olympia WA 98507.8039;V 1 ©1988-2011 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ,..,.r. 51,11 cL11 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 '} y+n.R"�1^r ••;r�•'+�.;� t; BKM6093 0415500 For Hire 05/29/2018 05/11/2019 A' ,t .�1�}t,5 'Ye Rr ,} t�ti ti + til' 4 +{P t;ti t1 Plate/Tag no Tab/Decal No Vehicle use type l r „�.� 1. , Gross Weight Gr wt start date Gross weight exp sate Fleet no Equip no Issue date Exp date r >> >t:,�,,t;,1 t t tt*'��,+ r 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 sti 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, conditicnal 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 Tp.120.802(CI'2'181 Page!of P Vehicle Information: BKM6093 2HKRL18962H528929 2002 HOND ODYSSEY Passenger Van Filing Registration Filing $3.00 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.dol.wa.gov. Skip a trip—go online www.dol.wa.gov c 0 010 TS> 2 0 0 0 RSR 0 rri 7-S \ � QFT 0 to k , � R! 6 - I CN : } 3 a) _- U 6 I i 0) ? ± CO ± : al d 272 . % 0 co ( < LD CD>� f k �� ƒ 33 ± ua «q - _ F- 5 - � cNi 0u_ \ . . m i g f y m Q 3 § �3 / / a �_ - C 0) Ct <C0 �>- : It ° Z 0 C ( � a - � ft0k Ct i--