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BRANDYN ERICKSON - EXP 12/2019 City of yeCm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Ye/n-7 are valid in Yelm, Olympia, Turnwater, and Lacey. [New Permit 0 Renewal (Permit # ) 1 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) For-Hire Driver 0 Locksmith 0 Solicitor APPLICANT INFORMATION \\ *Full Legal Name: �� (F/MIL) r�fl� ti c'l✓��� ' _rt c(<1U/1 Other Name(s) Used: (If additional space is needed, use the back of this page) (F/MIL) (F/M/L) Sex n *Date of Birth f 3/MI / *Age 7 SS# 73 9-�-3`LI C5 � tc'� *Height S ' I\` *weight ri q *Hair Color Dry*" *Eye Color 6I A._ Place of Birth s Anek Have you ever had an occupational permit suspended or revoked? :Wes {' to if, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for yourstreetaddress,s,please)e /� *Street I 7 � t( LA�e- K l�*City I`t° lei^^ *State _` /� Cr *ZI P q.%59 7 *Phone t�-53) 't 7 q —54 0 Cell *Mailing address (Larne *email r-e -0 c- 1E0rnovit G C1�1 Page 5 of 9 OTHER RECENT RESIDENCES List all other states and cities where you have lived in the past five (5) years. From 1 To State City m•nth/ ear mon ear • 5 BUSINESS INFORMATION (the business that is related to this permit) *Business Name K� ��� Business Owner/CEOe` Q.`� - L7 Applicant Street 2:22- g 4= City t6-e(t \ Stat ZIP�� Phone !-?G 1-1 S Cell -IlgZS' Email tk 0(.--6.4 ►&.k''' Yelm Business License# -ltd 41 EMPLOYMENT HISTORY Including your current employment, list the jobs you've held during the past ve (5) years. Job Title 4 Em•to er Ci IS to From/To 1 ,!, Yir- „ ,,� .. I iv._ i t/'nitIv 2 3 . fi5 *CRIMINAL HISTORY (Self-disclosure) in the past five (5) years, have you been convicted of any of the following o enses7 Offense Type Yes No 1 Anv felony 2Larceny/theft/vehicle prowling 3 I Domestic violence 4 i Fraud/Identity theft 5 Any drug-related crime 6 Any sex offense 7 i 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 05.03200 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 Z1 Make Itvpitekk, Modelvsej Color SC,d Plate# kc}t State (-PA Owner y-kk w,A KiAikczjrx T Vehicle 3 Vehicle 4 Year Make Model I Color PI to e 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 Have you had a valid Driver's License for the past two years? �( l l a If yes, in what state(s)? Wa A ;/-9 11 2 Are you 18 years old'? X f { ' 3 Do you have any physical or mental infirmities that may affect your driving? K( `` Have you been convicted of three(3) or more moving violations during any one i 1 (1) year period in the past five (5) years? In the past five (5) years, have you been convicted of operating a motor vehicle 5i x while under the influence of alcohol or drugs? . I In the past five (5) years, have you been convicted of having physical control of 6 1 a motor vehicle while under the influence of alcohol or drugs? 1 ; In the past five (5) years, have you been convicted of negligent driving Dr 7 I reckless operation of a motor vehicle? I iI In the past five (5)years, have you been convicted of vehicular homicide or x\ I $ I assault with a motor vehicle? I I *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, ydur State-issued ID card, Provide an ID photo. 0 Have your fingerprints taken at YPD. ,❑ Submit a copy of your complete driving record (for-hire driver/operator applicants only). , >it Submit your completed and signed application form. , \r.% Pay your fees(cash. check or debit card), Page 8 of 9 a 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 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. l Signature t - `7/Y �� DateO1 1 23/ E Q 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 QApproved ODenied Reason: 0lncomplete application QCriminal record 0Prior permit revocation 0False information 005.03.060 QOther(specify) ©Fees paid: Permit# QBase fee refunded: Date . 0Permit ID completed OApplicant notified By Date QPermit fee only (non-fingerprint renewal) Page 9 of 9 rt WASHINGTON DRIVER LICENSE 4dLIC#ERICKBJ09903 n,ERICKSON .1's' Z' 2 BRANDYN JAMES �, 3 DOB 09-23-1991 4a iss 09.09-2015 814510 119TH WAY SE YELM WA 985979593 is Sex M 19 Hgt 5.11 17 Wgt 150 18 Eyes GRN 9 Class 9a End NONE ab Exp 0 , 21 12 Restrictions NONE 1,110 1.41004"CAUCIA 5 DD ERICKBJ0990331152525F1721 Rev 59.16-2099 WASHINGTON STATE DEPARTMENT OF Driving Record - ERICKBJ099O3 CERTIFIED LICENSING Abstract of Driving Record-Insurance This information is current as of 9/21/2018 6:34 PM Driver Information Address Information License and ID Details DLN: ERICKBJ099O3 Address on file Personal Driver License: Last: ERICKSON Status: Licensed First: BRANDYN Issue: 09/09/2015 Middle: JAMES Expire: 09/23/2021 Suffix: Original issue: 09/09/2015 DOB: 09/23/1991 Gender: MALE State Identification Card: Issue: 04/30/2015 Expire: 09/23/2020 Original issue: 04/30/2015 Restrictions Endorsements Description Lic type Code Description Code No restrictions No endorsements Reinstatements Requirement No requirements DLN History DLN Start End ERICKBJ099O3 04/30/2015 Nonresident Licenses Jurisdiction License Number California E1699290 Tickets Description: B74- Fail To Show Insurance Finding date: 02/28/2017 Statute:46.30.020 CMV: No Certification Finding: Guilty Electronic ticket: No Hazmat: No Violation date: 01/14/2017 Court name:Thurston County Fatality: No Violation#: 7Z0154695 District Court No test: Exempt veh: No Mental health: No 16 Passenger: No Pass under 16: No Amended ACD: No 0 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. 1 of 1 City of yeCm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yeim are valid in YeIm. Olympia, Tumwater, and Lacey. IN New Permit Li Renewal (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 Yelrn.(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) For-Hire Driver ELocksmith EJSolicitor APPLICANT INFORMATION *Full Legal Name: (F/M/L) ((Ail ky,\ T-c-t rt'cKlodi Other Name(s) Used: (f additional space is needed, use the back of this page) (FIM/L) (F/M/L) Sex n -Date of Birth O / -3/(061 / *Age SS# 731 \ I\\ *Height *Weight ri 'Hair Color 1-)rvd/VA *Eye Color Place of Birth 'NCO trv-ib' \/V&k Have you ever had an occupational permit suspended or revoked? ElYes Jo If, "yes," when and where HOME ADDRESS (Do not use a P0, Box for your street address, please) *Street 16 5/ 7 Crt-‘etK [ct D*City *State 1114- *ZIP°Iii 5° 7 *Phone(253 <17ci —34 Cell *Mailing address ( ame r-erv\otC)—k €0_) 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 TM State City (m nth/year) (month/year) 1 3 4 6 _ BUSINESS INFORMATION (the business that is related to this permit) *Business Name ' ,•( Wye-LA-V) Business Owner/CEO Li Applicant Stieei g qt.-kW') City 16-Ain StatkdA ZIPq 'f-{1 Phone °0- )`-'11 Cell EmailKe-Vvi/Y-rt4. -esztio,C04-- Yelm Business License# \ •i( EMPLOYMENT HISTORY Including your current employment, list the jobs you've held during the past ve (5) years. Job Title Employer Ci IS -:te From/To — 4 A. ken._ 3 , 4 *CRIMINAL HISTORY (Self-disclosure) In the past five (5) years, have you been convicted of any of the following o enses? Offense Type , Yes No 1 Any felony 2 Larceny/theft/vehicle prowling 3 Domestic violence 4 Fraud/Identity theft 5 An drug-related crime 6 Any sex offense 7 1 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. 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 ZCC)Z- Make \civki1/4-SrA Model L Color SO\C‘ Plate# (b .vt•-\ (C.rtr-3 State LPik Owner VL\ vto1 Ki/k ri Vehicle 3 I Vehicle 4 Year Make Model Color 1 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 Have you had a valid Driver's License for the past two years? If yes, in what state(s)? la Valk) 2 Are you 18 years old? 3 Do you have any physical or mental infirmities that may affect your drivng? 4 Have you been convicted of three (3) or more moving violations during any one x (1) year period in the past five (5) years? In the past five (5) years, have you been convicted of operating a motor vehicle 5 while under the influence of alcohol or drugs? 6 In the past five (5) years, have you been convicted of having physicalC 0 ntrol 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 I reckless operation of a motor vehicle? I I In the past five (5) years, have you been convicted of vehicular homicide or 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. Submit a copy of your driver's license or, if no current driver's license, your State-issued ID card. Provide an ID photo. [i] Have your fingerprints taken at YPD. k] 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 appli'ation is true, accurate and complete to the best of my knowledge and belief. I also hereby authorize t e 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 hi-tory checks on me at any time while I hold an occupational permit issued under YMC 5,03, and I hereb, consent to such checks. Signature /,., -/"--77)-d-127 Date 1/ / CI I request a copy of the criminal history data used to determine my fit -ss for a permit. City use only below this line /71il4Vri tr'•, ir Date Received Reviewed By Review Date 2-11q ‘E3Aftroved LiDenied Reason: LiIncomplete application OCri inal record CiPrior permit revocation DFal.e information 005,03.060 Dot -r (specify) D ees paid: Permit# Base fee refunded Date Permit ID completed .-9-Applicant notified By (IC Date DPermit fee only (non-fingerprint renewal) Page 9 of 9 dtWASHINGTON STATE DEPARTMENT OF Driving Record - ERICKBJ099O3 CERTIFIED LICENSING Abstract of Driving Record-Insurance This information is current as of 9/21/2018 6:34 PM Driver Information Address Information License and ID Details DLN: ERICKBJ099O3 Address on file Personal Driver License: Last: ERICKSON Status: Licensed First: BRANDYN Issue: 09/09/2015 Middle: JAMES Expire: 09/23/2021 Suffix: Original issue: 09/09/2015 DOB: 09/23/1991 Gender: MALE State Identification Card: Issue: 04/30/2015 Expire: 09/23/2020 Original issue: 04/30/2015 Restrictions Endorsements Description Lic type Code Description Code No restrictions No endorsements Reinstatements Requirement No requirements DLN History DLN Start End ERICKBJ099O3 04/30/2015 Nonresident Licenses Jurisdiction License Number California E1699290 Tickets Description: B74-Fail To Show Insurance Finding date: 02/28/2017 Statute:46.30.020 CMV: No Certification Finding: Guilty Electronic ticket: No Hazmat: No Violation date: 01/14/2017 Court name: Thurston County Fatality: No Violation#: 7Z0154695 District Court No test: Exempt veh: No Mental health: No 16 Passenger: No Pass under 16: No Amended ACD: No 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. 1 of 1 • u AWASHINGTON DRIVER LICENSE w>` 4d L.IC#ERICKBJ09903 ERICKSON .r-4;.:,. z BRANDYN JAMES 3 DOB 09-23-1991 as iss 09-09-2015 814510 119TH WAY SE YELM WA 98591-9593 ,yam is Sex M ts Hgt 5-11 17 Wgt 150 18 Eyes GRN 9 Class 9a End NONE ab Exp 21 12 Restrictions NONE 5 DD ERICKBJ0990331152525F1121 Rev 89-16.200