HomeMy WebLinkAboutApplication APPLICANT 11/23/2021(City of Springfield
Development & Public Works
225 Fifth Street
Springfield, OR 97477
PERMIT REVIEW INTAKE FORM
SPRINGFIELD
W 0#1
(City Staff completes form)
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Dept of Motor Vehicles -New: ❑ Land Use Compatibility Statement ❑ City: ❑
Dept of Motor Vehicles -Renewal: x Zoning Verification Letter: ❑ GB: 11
Project Information
Applicant Name: Springfield Auto Rec clers
Phone: 5417479601
Company:
Cell:
Address: 750 South 281^ Street Springfield Or 97477
Property Owner: Charles Harral
Phone:
Company:
Cell:
Address: PO Box 127 Springfield Or 97477
ASSESSOR'S MAP NO: 18030100
TAX LOT NOS : 100
Property Address: 750 S 281^ Street Springfield Or 97477
Description of Proposal: DMV wreckers license renewal
Record Information
Record No: 811-21-000307-TYP1
Date Received:
11/23/21
Application Fee: $ 348
Technical Fee:
$17.40
TOTAL FEES: $365.40 Assigned Planner: Liz Miller
Revised 11.2.11 kl
INSTRUCTIONS FOR COMPLETING AN APPLICATION
FOR AN ANNUAL DISMANTLER CERTIFICATE
-•w••- ��� (Originals and Renewals)
OFFICE HOURS for Business Licensing in the Salem DMV Headquarters office: I
8:00 a.m. - 4:30 p.m., Monday through Friday, except Thursdays 9:00 am - 4:30 P.m. (closed holidays).
Read the entire application before completing it. This application will be returned to you if incomplete.
Submit your completed application and fees to:
DMV Business Licensing
1905 Lana Ave NE
SALEM OR 97314
Phone: 503-945-50521 Website: www.oregondm¢com / Email: DMVinsert@odotstate.or.us
RENEWALS: H renewing between 15 days and 45 days AFTER your certificate expires, add a late fee of
$150. When submitting your application and fees at the Business Licensing counter (1965 Lana Ave NE):
• If paying cash, please have exact amount since Business Licensing cannot make change.
• Make copies of your application for your records.
Legal Name — If year business is a sole proprietorship, list your full name as the legal name. If your business is a partnership, list the full names of
each partner. If your business is an LLC, list the name of the limited liability company (includes "LLC") registered with the Office of the Oregon
Secretary of State Corporation Division (Business Registry). If your business is a corporation, list the name of the corporation registered with the
Oregon Business Registry.
Business Name — If using an assumed business name or trade name, list the business name registered with the Office of the Secretary of State
Corporation Division. Otherwise, your dismantler certificate will be issued using its legal name.
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) — Provide your FEIN, not your SSN. For more information go to
helps://ww.v.IRS.gov.
Oregon Business Registry Numbers — If you do not knew or you do not have your Business Registry number(s), contact the Office of the
Secretary of State Corporation Division for this information at 503-986-2200 or go to https://sos.oregon.gov/business.
Main Business Location — Business location where dismantling business is being (or will be) conducted.
Type of Organization — Check your organization type and if a corporation, list the state where the business is incorporated.
National Motor Vehicle Title Information System (NMVrIS) — Provide your NMVTIS number. To obtain a NMVTIS Reporting ID, register at
https://www.vehiclehistory.gov.
Description of the Location of the Dismantling Business — To verify compliance with ORS 822.115 and 822.135, submit a plat map or other
acceptable site information that clearly shows compliance with all legal requirements. You must also provide the dimensions of the property where
the business is located.
Local Government Approval —Pursuant to ORS 822.140, an applicant must comply with any regulation established by a city or county zoning, and
must obtain the approval of the city or county governing body. Take your dismantler application to the applicable city or county office for their
approval; (DMV will not accept If location approval is more than 6 months aid). Some cities and counties charge a fee for signing the application.
Registered Agent — The registered agent's name, street address and mailing address are required, and must be consistent with the registered
agent identified in the Business Registry.
DEQ Permit Requirements — If the dismantler business is required by the Oregon Department of Environmental Quality (DEQ) to
possess any permits issued by DEQ, list the permit name(s) & number(s), and describe the permit requirements.
Ownership/Applicant's Certification Signature — Provide the name, residence address, mailing address and signature of
owners, partners, LLC members or corporate officers on Page 3 (do not list CEOs, Chairs of the Board, General Managers, Directors).
Every owner, partner, member or officer listed on the application must provide a certifying signature. Attach (staple) copies of all listed
person's valid, government -issued photo ID to the application. The copy must be legible. If the residence address on the photo ID and
on Page 3 are not the same, attach a statement explaining why they do not match.
Bond or Letter of Credit — The bond or letter of credit required for a dismantler certificate must be in the sum of $100,000
and must be completed, signed and sealed by the bonding company. The owner, a partner, an LLC member or a corporate officermust
sign the bond. The legal name, business name and business location on the bond must match the dismantler application. The bond must expire on
the last day of the month.
Fire Response Plan —A fire response plan is a document that must be submitted with new and renewal applications and must contain:
(1) Procedures for reporting an incident to emergency fire -fighting resources;
(2) Procedures for notifying people on the premises of the protocol for reporting an incident and emergency evacuation, and
sterling people on the premises to a current emergency:
(3) Procedures for emergency evacuation, including a diagram or map of evacuation routes and the occupancy assembly point;
(4) A diagram or map of the routes of fire department vehicle access; and
(5) A diagram or map of fire hydrant locations, If any, at or within 500 feet of the dismantlers premises (wrecking yard).
Supplemental Location Using The Same Business Name — A separate supplemental application (Form 735.373A) must be completed for each
additional location where you operate the dismantler business. You must conduct business at each supplemental [Mellon under the same name as
the primary location, which includes obtaining the local government's approval for the supplemental location.
Renewal Application Requirement — In addition to the applicaton requirements for initial application, a renewal application must also include a
copy of the local fire inspectors report based on an inspection of the applicant's business premises conducted within 12 months preceding the
expiration date of the current dismantler certificate for each business location (supplemental location(M and main location).
ADDITIONAL INFORMATION
CHANGING YOUR BUSINESS NAME -You need to file a correction application (Form 735.9738) with Business
Licensing before you conduct dismantler business using a new name. The correction application needs to be signed by
an owner, partner, LLC member, or corporate officer and include a bond rider from your bonding company.
• Contact the Oregon Secretary of State Corporation Division at 503-986-2200 or
https;//sos.oregon.gov/business to change your business name (update Business Registry information).
• There is no fee for a name change.
CHANGING YOUR BUSINESS LOCATION - If you move your disman0er business location, you need to Ole a
correction application (Form 735-3736) with DMV before you conduct dismantler business at the new location. The
correction application needs to be signed by an owner, partner, LLC member, or corporate officer and include:
• Location approval from the city or county;
• A bond rider from your bonding company; and
• A plat map or description of the location of the premises; and
• Information for any required DEQ Permits;
• Fire response plan;
• There is no fee for a location change.
CHANGING YOUR BUSINESS NAME AND LOCATION - You need to file a correction application (Form 735-373B)
with the Business Licensing Unit if you change your business name AND location. The correction application needs
to be signed by an owner, partner, LLC member, or corporate officer and include:
• Location approval from the city or county;
• A bond rider from your bonding company;
• A plat map or description of the location of the premises; and
• Contact the Secretary of State Corporation Division at 503-986-2200 or
https:/Isos.oregon.gov/business to change your business name.
• Information for any required DEQ Permits;
• Fire response plan;
• There is no fee required.
OTHER CHANGES - You need to file a correction application (Form 735.3738) with DMV if you add or remove a partner,
LLC member or corporate officer or change your ownership structure (e.g., individual to partners, partners to corporation,
LLC to corporation, etc.). The correction application needs to be signed by an owner, partner, LLC member, or corporate
officer (including all new owners, partners, LLC members or corporate officers being added or removed) and include:
• A bond rider from your bonding company;
• A copy of a valid government -issued photo ID for any owner/partner/member additions to the business.
• There is no fee required.
SUPPLEMENTAL CERTIFICATE - A supplemental business certificate is required for each additional location
where you conduct dismantler business. The supplemental location must use the same business name as
the primary location. A supplemental application must be filed with DMV before you conduct dismantler business at
the additional location. The supplemental application (Form 735-373A) must be signed by an owner, partner,
LLC member, or corporate officer and include:
• Location approval from the city or county:.
• A plat map or description of the location of the premises;
• An endorsement from your bonding company (you may attach a rider);
• Information for any required DEC Permits;
• Fire response plan; and
• A fee of $500.
DUPLICATE CERTIFICATE - If you need a duplicate dismantler certificate issued, contact Business Licensing.
The fee is $40.
If you have any questions, please contact Business Licensing at 503.945-5052.
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APPLICATION FOR CERTIFICATE NUMBER
0
ANNUAL BUSINESS CERTIFICATE EFFECTIVE DATE
AS A DISMANTLER OF MOTOR VEHICLES OR
"'"'^"•°"'"°""°°"^"' SALVAGE POOL OPERATOR FEE: $500 EXPIRATION DATE
• PLEASE TYPE OR PRINT LEGIBLY WITH INK.
• ANY ALTERATION OF LINE 3 VOIDS LOCATION APPROVALI ❑ORIGINAL ❑RENEWAL
LEGAL NAME OFAPPLICANT(Ci PARTNERSHIP, LLCOR CORPORATION NAME)
FEDERAL ELWLOYEE IO NUMBER (FEIN)
OREGON REGISTRY NUMBER RF LLC OR CORPOMIMN)
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9- 63
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B 51 NAME F PPLICANT IFAB$UMED BUSINESS XAME R'TMDE ME)
PRE,BN REG6SRIY NU BEP
FVbI PSSVM®aU51N NAMEGRIRADENPMFJ
BUSINESS TELEPHONE
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MAIN BUSINESS LOCAS N�(SoTRKEAN
CIN
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CHECR ORGANuanon TYPE 0 corporalion, list the stale where
❑Individual ❑Partnership ❑LLC Corporation:
the business is Incorporated:
OREGON REGISTERED AGENT NAME
Lan UL
TELEPHONE NUMBER
OREGON REGISTERED AGENT STREET ADDRESS
CITY
STATE
ZIP CODE
b l oto ¢ 00
P-
7 7
OREGON REGISTERED AGENT MAILING ADDRESS (IF DIFFERENT)
CITY I
STATE
I ZIP CODE
National Motor Vehicle Title Information System (NMVTIS) number REQUIRED: Q D p 2 t7 41
a) THE DIMENSIONS OF THE PROPERTY ON WHICH THE BUSINESS IS LOCATED ARE nO ft. X 00 it.
Ii ORS 822.115(4) requires applicants to file a description of the location of the dismantling yard. Accordingly,
please submit a plat map or other description of the location of the premises.
LOCAL GOVERNMENT APPROVAL (CITY / COUNTY)
THE CERTIFICATION BELOW IS TO BE COMPLETED BY THE LOCAL ZONING OFFICIAL.
By signing this application you are authorizing a dismantler business to be conducted at the location listed
on Line 3 of this application. If a dismantler business cannot be conducted at this location, do not sign
this approval.
❑ I represent an incorporated city with a papulation of 100,000 or more.
By signing on Line 13, 1 certify that pursuant to ORS 822.110(t)(a) the address listed as the place of business for use in the motor vehicle
dismantling business is zoned for industrial use or subject to another zoning classification that permits the type of business conducted by
the dismantler.
❑ I represent a county, or an incorporated city with a population of less than 100,000.
By signing on Line 13, 1 certify the following:
❑ CITY
THAT THE GOVERNI NG BODY OF THE OF HAS:
1:1 COUNTY
A) APPROVED THE APPLICANT AS BEING SUITABLE TO ESTABLISH, ♦ PLACE STAMP OR SEAL HERE
MAINTAIN OR OPERATE A MOTOR VEHICLE DISMANTLING BUSINESS
(ORIGINAL APPLICATIONS ONLY).
B) DETERMINED THAT THE LOCATION OR PROPOSED LOCATION MEETS
THE REQUIREMENTS FOR THAT LOCATION UNDER ORS 822.110.
C) DETERMINED THAT THE LOCATION DOES NOT VIOLATE ANY
APPLICABLE PROVISION OF ORS 822.135.
D) APPROVED THE LOCATION AND DETERMINED THAT THE LOCATION
COMPLIES WITH ANY REGULATIONS ADOPTED BY THE JURISDICTION
UNDER ORS 822.140.
El Restrictions on the location approval are in an attached letter from the
zoning authority.
I ALSO CERTIFY THAT I AM AUTHORIZED TO SIGN THIS APPLICATION AND AS EVIDENCE OF SUCH AUTHORITY DO
AFFIX HEREON THE SEAL OR STAMP OF THE CITY OR COUNTY.
MMEOFGOVERNRIENTGFFICML
TIT
PHONE NUMBER
( )
SIGNATURE OFGOVERNMENT OFFICIAL
DATE
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PRINCIPAL(S) DISMANTLER HISTORY
Information on the principals of this business is required under Oregon Revised Statutes (ORS) 822.115.
OAR 735-152-0000(19) defines principal as 'any owner of a partnership, corporate officer, proprietor of a sole
proprietorship, LLC member,. or other person who Controls the business entity.
Please provide the following Information about all owners listed on this application and other principal(s) of
the business:
Has any principal of this dismantler business been financially or operationally involved in any jurisdiction, including
Oregon, with a vehicle dismantler business whose certificate or right to apply for a certificate was revoked or is
currently suspended?
-5�1„NO ❑ YES, revoked currently suspended. If "YES," complete Section 16.
NAME OF DISMANTLER BUSINESS
PRINCIPAL'S NAME
DISMANTLER CERTIFICATE NUMBER
STATE WHERE SUSPENDED I Ri
DATE OF SUSPENSION/REVOCATION
I EXPIRATION OF SUSPENSION
Have you ever been an owner or principal on a vehicle dismantler certificate in Oregon (excluding current application)?
NO ❑ YES: If "YES," complete Section 18.
NAME OF DISMANTLER BUSINESS
PRINCIPAL'S NAME
DISMANTLER CERTIFICATE NUMBER
BUSINESS LOCATION INFORMATION:
Property is(check one):OWNED ❑ LEASED/ RENTED: LEASE OR RENTAL PERIOD:
If property is "Leased / Rented" complete the following:
PROPERTY OWNER'S FULL NAME
TELEPHONE NUMBER
PROPERTY OVVHER'S ADDRESS
GIN
STATE
ZIP CODE
APPLICANT:
By signing this application you are certifying that:
I . The right-of-way of any highway adjacent to the area proposed for approval to conduct the dismantling business is approved and used for access
to the premises and public parking,
2. Except on interstate or primary highways within a zoned area allowing wrecking yards and dismantling businesses.. you maintain a building or
enclosure or other barrier to a height of six feet for the purpose of conducting business:
3. You will not store any vehicles or vehicle parts or conduct the dismantling business outside of the building, enclosure or barrier:
4. The business is hidden or adequately screened by the terrain or other natural objects, plantings, fences or other appropriate means so as not to
be visible from the main traveled way of the highway except as permitted by ORS 822.135 and OAR 734-040-0030.
False certification is a Class B misdemeanor under ORS 162.085 and is punishable by six months in jail, a fine of up to
$2,500 or both. In addition, civil penalties and DMV sanctions againstou or your dismantler certificate may be imposed. I
certify that I am the owner, a partner, an LLC member, or a corporate opcer of this business and that all information on this
application is accurate and true. Complete the section(s) below and sign.
Complete the section(s) below and sign.
(Be sure to attach a separate sheet to show additional owners.)
• List the primary owner, partners, LLC members or corporate officers below.
• If a member of a limited liability company (LLC) is a corporation, the president must provide information below.
• If a partner of a partnership is a corporation, the president must provide information below.
• If a corporation or LLC. then Oregon registered agent name and address required below.
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OWNERSHIP INFORMATION
PRINT yp OF OWNER/PARTNERILL MEM9ER/CORPORATEOFFICER
! l// r e (� certraQ
TITLE
%�rcS
TELEPHONE NUMBER
5 i� -35
DATEOFBIRTH DRIVER LICENSE NOMBER
I I (T L_ o I }
STATE OF ISSUANCE
OIZ
EMAIL
(took
RESID.NCEA DRESS
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CITY
sqj
STATE
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ZIP OFF
4-rq-
MAILING ADDRESS (IF DIFFERENT)
I -P,O.
CIN
STATE
OiLITTY71
I ZIP CODE
CERTIFYING R WN ON LINE2
rX
DATE
PRINT NAME OF OWNER/PARTNER/LLC MEMBER /CORPORATE OFFICER
TITLE
TELEPHONE NUMBER
DATE OF BIRTH
(
DRIVER LICENSENUMBER
STATE OF ISSUANCE
EMAIL
RESIDENCE ADDRESS
CITY
STATE
ZIPCODE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP CODE
CERTIFYING SIGNATURE OF PRINCIPAL SHOWN ON LINE 27 ABOVE DATE
PRINT NAME OF OWNER/PARTNER/LLC MEMBER/CORPORATE OFFICER
I
TITLE TELEPHONE NUMBER
DATE OF BIRTH
DRIVERLICENSE NUMBER
STATE OF ISSUANCE EMAIL
RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP CODE
CERTIFYING SIGNATURE OF PRINCIPAL SHOWN ON LINE 32 ABOVE
X
PATE
Are there any applicable permits required by Oregon Department of Environmental Quality (DEQ)?
�NO ❑ YES: If "YES," complete Section 38.
DEQ PERMIT TITLE/NUMBER(S)
DATE OF ISSUE
DATE OF EXPIRATION
REQUIREMENTS PERTAINING TO DISMANTLER BUSINESS OR PREMISES (ATTACH A SEPARATE PAGE FOR DESCRIPTION AND/OR ADDITIONAL PERMITS IF NECESSARY
Attach (staple) copies of ALL owners, partners, LLC members or corporate officers' valid government photo
IDs (driver license or state issued identification card ONLY). If the residence address on the photo ID is
different than the residence address listed on the application, submit a statement explaining why the
addresses do not match.
O Copy must be legible. O
Fire Response Plan Required - Attach a fire response plan as described in the instructions.
O D
Renewals ONLY: - Attach a copy of the fire inspectors report based on an inspection of the business premises.
Inspection cannot have occured more than one year before renewal date.
O D
Page 3
SURETY BOND • BONDNUMBER •
NOTE., TO BE COMPLETED BY BONDING COMPANY. FAILURE
TO ACCURATELY COMPLETE THIS FORM WILL CAUSE
DELAY. PLEASE TYPE OR PRINT LEGIBLY WITH INK.
LET IT BE KNOWN:
THAT
(INDIVIDUAL NAME OF OWNER, ALL PARTNERS OR MEMBERS, OR NAME OF CORPORATION
DOING BUSINESS AS
(BUSINESS NAME AS GIVEN ON THE CERTIFICATE APPLICATION
HAVING PRINCIPAL PLACE OF BUSINESS AT
(ADDRESS, CITY, STATE, ZIP CODE)
WITH ADDITIONAL PLACES OF BUSINESS AT
(ADDRESS, CITY, STATE, ZIP CODE)
(ADDRESS, DITO STATE, ZIP CODE)
STATE OF OREGON, AS PRINCIPALIS), AND
SURETY NAME( /
l
(ADDRESS, CITY, STATE ZIP CODE) TELEPHONE NUMBER
A CORPORATION ORGANIZED AND EXISTING UNDERAND BY VIRTUE OF THE LAWS OF THE STATE OF-, AND AUTHORIZED
TO TRANSACT A SURETY BUSINESS IN THE STATE OF OREGON, AS SURETY, ARE HELD AND FIRMLY BOUND UNTO THE STATE OF OREGON
IN THE PENAL SUM OF $100,000 FOR THE PAYMENT OF WHICH THE PRINCIPAL(S) AND SURETY JOINTLY AND SEVERALLY BIND THEMSELVES,
THEIR RESPECTIVE SUCCESSORS, AND ASSIGNS.
WHEREAS, THE PRINCIPAL(S) IS APPLYING FOR A DISMANTLER CERTIFICATE ISSUED BY THE OREGON DEPARTMENT OF TRANSPORTATION.
THE CONDITION OF THIS OBLIGATION IS SUCH THAT, WHEN THE ABOVE-NAMED PRINCRAL(S) IS ISSUED A DISMANTLER CERTIFICATE TO
CONDUCT A MOTOR VEHICLE DISMANTLING BUSINESS IN THIS STATE, SAID PRINCIPALIS) MUST CONDUCT SUCH BUSINESS WITHOUT
FRAUD OR FRAUDULENT REPRESENTATION, AND WITHOUT VIOLATION OF ANY OF THE PROVISIONS OF THE OREGON VEHICLE CODE
SPECIFIED IN ORS 822.120, THEN AND IN THAT EVENT THIS OBLIGATION TO BE VOID, OTHERWISE TO REMAIN IN FULL FORCE AND EFFECT
UNLESS CANCELED PURSUANT TO ORS 742.366(2).
THIS BOND IS EFFECTIVE AS OF THE DATE THE PRINCIPAL(S) IS ISSUED A DISMANTLER CERTIFICATE BY THE OREGON DEPARTMENT OF
TRANSPORTATION UNTIL DEPLETED BY CLAIMS PAID, UNLESS THE SURETY SOONER CANCELS THE BOND. THIS BOND MAY BE CANCELED
BY THE SURETY GIVING WRITTEN NOTICE OF SUCH CANCELLATION TO THE DRIVER AND MOTOR VEHICLE SERVICES DIVISION OF THE
OREGON DEPARTMENT OF TRANSPORTATION. THIS BOND SHALL EXPIRE UPON EXPIRATION OF THE DISMANTLER CERTIFICATE,
BUT MY BE RENEWED UPON THE RENEWAL OF THE CERTIFICATE.
THIS BOND SHALL BE ONE CONTINUOUS OBLIGATION AND THE LIABILITY OF THE SURETY SHALL BE LIMITED TO THE AMOUNT OF THE
PENALTY OF THIS BOND REGARDLESS OF WHETHER THIS BOND IS RENEWED OR OTHERWISE CONTINUED IN EFFECT UPON ITS ORIGINAL
TERM.
THIS BOND IS EFFECTIVE AND EXPIRES ./ BOND MUS. SAPIRE ON THE
LAST DAY OFTHE MONTH
(MONTH, DAY, YEAR) (MONTH, DAY, YEAR)
-- ANY ALTERATION VOIDS THIS BOND -
IN WITNESS WHEREOF, THE SAID PRINCIPAL(S) AND SAID SURETY HAVE EACH CAUSED THESE PRESENTS TO BE EXECUTED BY ITS AUTHORIZED
REPRESENTATIVE OR REPRESENTATIVES AND THE SURETY CORPORATE SEAL TO BE HEREUNTO AFFIXED
THIS DAY OF
(DAY) luoNTp GEAR)
SIGNATURE (OWNERPARTNERIMEMBER OR CORPORATE OFFICER)
TITLE
X
SIGNATURE OF SURETY (AUTHORIZED REPRESENTATIVE)
TITLE
X
SURETY'S AGENT OR REPRESENTATIVE MUST COMPLETE THIS SECTION:
PLACE SURETY SEAL BELOW
IN THE EVENT A PROBLEM ARISES CONCERNING THIS BOND, CONTACT:
NAME
TELEPHONENUMBER
ADDRESS
Cf1Y, STATE, EIP CODE
APPROVED BY ATTORNEY GENERAL'S OFFICE
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