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Home My WebLink AboutScrap Metal License Addendum - PLN General - 10/30/2015 c ��STATE State of Washington 26 (1 _� r (.Jl..l./5 Bi Business Licensing �� /> ter^ z PO Box 9034 J Olympia,WA 98507-9034 Owner name Hf iaee�� 1-800-451-7985 PARCEL FILE s � � Scrap Metal License Addendum (To apply for a license as a Scrap Metal Processor,Scrap Metal Recycler,and/or Scrap Metal Supplier) This addendum form may only be submitted as an attachment to the Business License Application. Licenses and Vehicle Plates Requested (Select all that apply to your business.) ❑ Scrap Metal Processor (248) ❑Scrap Metal Recycler(252) ❑Scrap Metal Supplier(255) Fee:$1,250.00 Fee:$1,250.00 Fee:$350.00 No.of Processor vehicle plates: No.of Recycler vehicle plates: No.of Supplier vehicle plates: Be sure to submit the appropriate fees for the number of plates requested: $5.00 for the first plate of each type, and$2.00 for each additional plate of the same type ■ ■ Business Site Identification (Certification in section D applies to the following business location) 1 Business Firm Name Business Telephone Number �" s l� ,M ) Y71 Business phykiraj to lion address Street or rural route Do not use PO box number L 1 10 City County � state Zip C�10 Additional Information and Documentation (See instruction sheet for explanations) All applicants must attach the following completed documents to this application: ❑Corporate or LLC Information Sheet (Corporations and Limited Liability Company applicants only) ❑Personal/Criminal History Statement(s) In addition to the above, Scrap Metal Processor and Scrap Metal Recycler applicants must also provide: ❑Surety Bond(s) Local Authority - Certificate of Approval (All applicants) Before submitting your Business License Application, you must arrange for the appropriate authority to review and approve your application, and sign this form.The approving authority may require an onsite inspection before signing. For businesses located inside an incorporated city or town the approving authority must be the local chief executive officer or chief of police, or their designee. For businesses located in an unincorporated area the approving authority must be the county legislative authority, county sheriff, or their designee.To see a list of approving authorities by location, go to dol.wa.gov/business/scrapmetal/approvallist.html. Inspecting Official:Check either"yes"or"no"for each option, then sign. 1. Applicant is applying as a Scrap Metal Supplier...................................................... 'VYes No 2. Applicant is applying as a Scrap Metal Processor.................................................... ❑Yes &No 3. Applicant is applying as a Scrap Metal Recycler...................................................... ❑Yes allo My signature below certifies the following:The applicant's scrap metal business is located at the address listed in Section B. The business is not prohibited from operating at that location' by any known local environmental, building code, zoning, or other land use regulation violations. "(D Comments` �Y'.. �„[�1S r U��,-1t2 C'lU ►'�f�? l L� ,,�c S-- Si u of Loca'Aythority Print me 1 1 le of Local Authority Phone Number ate Signed r For assistance or to request this document in an alternate format,visit://business.wa.gov/BLS or call 1-800-647-7706.Teletype(TTY)useri may usd the Washington Relay Service by calling 711. BLS-700.189(4/3/14) State of Washington UBI number Business Licensing Service t 5 - x PO Box 9034 Olympia,WA 98507-9034 dh`'"ay goy 1-800-451-7985 Personal/Criminal History Statement (For Vehicle and/or Vessel Dealer,Wrecker,Hulk Hauler,Scrap Processor,Scrap Metal Recycling or Commercial Telephone Solicitor) Please type or print clearly in dark ink.Complete all spaces or print N/A in spaces that do not apply. Type of license(s)you are applying for: (A copy of this form will be provided to the agency that regulates the license.) ❑Vehicle and/or Vessel Dealer ❑Wrecker/Hulk Hauler/Scrap Processor ❑Scrap Metal Business ❑Commercial Telephone Solicitor I i Personal statement Busine s name DBA or trade name Email Address w N fr' Bust ess location address Street or route City County State or country Vs— _ ter/ tiv5 '�i c heck all that apply: I am a: f Sole proprietor ❑ Spouse ❑ Corporate officer ❑ LLC member/manager ❑ Manager` ❑ Partner l Manager is needed only if you are applying for a Commercial Telephone Solicitor license Name Last First, Midde Maiden Social security number ` Birthdate mm/dd/yy - ( y_ :�- d- 7 Home mailing address Street or ro e,PO box Ci C my State or country Zip code h'I 7,5 A1160 kw 1 (Area code)Home telephone number (Area code)Work/cell telephone numbe (Area code)Fax number Criminal history 1. Have you ever been convicted of a misdemeanor,gross misdemeanor,felony,or are you subject to any �( currently effective injunction or restrictive court order?................................................................................................................... 7 Yes ❑ No If yes, enter the information requested below and attach additional sheets as needed. Conviction Date Charge City,county and state Disposition Docket number 2. Have you ever had a judgement rendered against you? .......................................................................................... ❑ Yes ,B'No If yes, enter the Information requested below and attach additional sheets as needed. Conviction Date Charge City,county and state Disposition Docket number Business license and registration history 1. Do you currently have,or have you had, a vehicle and/or vessel dealer,wrecker, hulk hauler,scrap processor, or commercial telephone solicitor license in this or any other state?................................... .................................................. Z Yes El If yes, enter the information requested below and attach additional sheets as needed. License number State Date(s) Type of business license or registration 2. Have you ever had disciplinary action taken against you or have you ever terminated a license in lieu of disciplinary action? If yes, explain on a separate sheet........................................................................................ ❑ Yes L;'Klo 3. Is your current business structure changing?...................................................................................................................................... ❑ Yes ,2 NNo Certification 1. Do you understand that untruthful or misleading answers may be cause for denial of a license and/or revocation ofany license granted?................................................................................................................................................................................. ,e Yes ❑ No 2. Do you authorize investigation of your criminal history,financial records and credit history as necessary for licensing?............................................................................................................................................................................................................ ;?Yes ❑ No I certify(or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signature Date signed X Printed name of person signing above Place signed (City,county,state) For assistance or to request this document in an alternate format,please visit http://b/s.dor.wa.gov/BLS or call 1-800-647-7706.Teletype(TTY)users may use the Washington Relay Service by calling 711. BLS-700-324(8/3/1 5)