HomeMy WebLinkAboutApplication Applicant 7/20/2023City of Springfield
Development & Public Works
225 Fifth Street
Springfield, OR 97477IL,
SPRINGFIELD
LAND USE COMPATIBILIITY STATEMENT (LUCS), DEPARTMENT OF
MOTOR VEHICLES (DMV) and ZONING VERIFICATION LETTER
Application form
Permit Type
Dept of Motor Vehicles -New., Land Use Compatibility Statement: ❑ City:
Dept of Motor Vehicles -Renewal: ❑ Zoning Verification Letter: ❑ UGB: ❑
Project Information
Applicant Name: Phone: S L1 - (>53
Company:
(�� .ii E-mail:
Address: % b a +n SSI-
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Phone:S Q 1-4
Company:
E-mail:
Address: lM a , A g �'
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ASSESSOR'S MAP NO:
Property Address: (� (0 1m cr'
TAX LOT NOS
Description of proposal/ request:
Record Information (Staff to complete)
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Record No: �11-a8 - 000 "'J' flP1
Date Received: -7
Application Fee: $ -3(05.00
TOTAL FEES: $ `�
Technical Fee: $
Assigned Planner:
Revised 2023 04 04 slm
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APPLICATION FOR
THREE YEAR VEHICLE DEALER CERTIFICATE
WPAff MENf OF iNANW0WAf10N
° LP"A"°"W8AL OR AS A DEALER OR REBUILDER OF VEHICLES
1905 LAN11 AVE NE, SAIHI ONEGON •fJ14
CUSTOMER NUMBER EFFECTIVE DATE EXPIRATION DATE DEALER NUMBER
❑ ORIGINAL
❑ RENEWAL
i CERTIFICATE
FEE
If this is a renewal, do not complete the fee information. Use the
attached billing list to calculate your fees. The billing list MUST be submitted
•
with your renewal application.
LATE
FEE
Original Certificate Includes one late $1,187.00
SUPPLEMENTALS
PLATES
Additional Locations @$350.00 ..................... $
RENEWAL
(Supplemental Application Form 735-372 required for each
location) $ 0-00
ADDITIONAL
PLATES
TOTAL
$
Additional plates 12" x 6" or 7" x 4" $54.50...
(Two sizes, standard and small, available) TOTAL = $1,187.00
>- TEMPORARY
PLATES
BUSINESS NAME AND ADDRESS Any alteration of Line 3 voids location approval.
LEGA E OF APPLICANT (OWNER, PARTNERSHIP, LLC OR CORPORATION NAME)
FEDERAL ID NUMBER (FEIN) OREGON REGISTRY # (IF LLC OR CORPORATION)
v�
a--D4SI --4� a�Li � 6
BU INE NAME (IF ASSUME BU ESS NAME, FILL IN RE TRY NO.)
S
EGON REGISTRY NO.
51q16HG9
BUSINESS TELEPHONE
3
I � MJV� ��-o� t�[
541-65`t-�A
MAI BUSINESS LOCATION (STREET AND NU BER)
CITY
ZIP
+CODE
C1OUN/T�Y�A,
H 10
/ M/
MA1INGADDRESS
r
TATE
ZIP CODE
EMAIL ,IVa Gb
TYPE OF OPERATION If corporation, list the state under
which business is incorporated:
CHECK ORGANIZATION TYPE: ❑ Individual ❑ Partnership LLC ❑ Corporation:
/ we primarily sell: ❑ New Vehicles Used Vehicles
I /we are a franchise dealer: Yes Ltj No If "Yes," name the makes
I / we sell NEW RECREATIONAL VEHICLES: [:]Yes � No
IF "YES," SERVICE FACILITY LOCATION (STREET AND NUMBER) CITY ZIP CODE
LOCATION APPROVAL (If renewal, required only if dealer is changing business location)
Certification of local zoning. ORS 822.005 requires a vehicle dealer certificate, unless exempt under ORS 822.015, for any person
who:
(a) Buys, sells, brokers, trades or exchanges vehicles either outright or by means of any conditional sale, bailment, lease,
security interest, consignment or otherwise; OR
(b) Displays a new or used vehicle, trailer, or semitrailer for sale; OR
(c) Acts as any type of agent for the owner of a vehicle to sell the vehicle or acts as any type of agent for a person interested
in buying a vehicle to buy a vehicle.
THE CERTIFICATION BELOW IS TO BE COMPLETED BY THE LOCAL ZONING OFFICIAL. The approval below should be based
upon whether the applicant can do ANY of the activities listed in (a) through (c) above under applicable ordinances, at the location
of the business given on Line 3. Pursuant to ORS 822.025, applicant shall meet requirements below.
As the zoning official for the jurisdiction where this business is located, I verify by my signature that the location of this business as stated on this application
complies with any land use ordinances of the jurisdiction pursuant to ORS 822.025.
F-1❑COUNTY OF:
TELEPHONE NUMBER
CITYOF:
PRINT NAME TITLE
SIGNATURE DATE
X
0 place stamp or seal hers O
❑ Check box if restrictions on the location
approval are in an attached letter from
the zoning authority.
735-37012-23)
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BUSINESS LOCATION INFORMATION:
LEASED / RENTED: LEASE OR RENTAL PERIOD: �--
Property is (check one): ❑ OWNED 7q 91
If property is "Leased / Rented" complete the following:
she+
PROPERTY OWNER'S FULL NAME (As onoCounty Property Records) TELEPHONE NUMBER
IZ 1(` 41 N
Vr� i 1
PROPERTY OWNER'S MAILI G b-ORE5S CITY
STATE
ZIP CODE
a I 'A �kA ro
(Be sure to attach a separate sheet to show additional owners.)
Listthe primary owner, partners, LLC members or corporate officers.
• 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 corporation or LLC, the Oregon registered agent name and addresses are required below.
OREGON REGISTERED AGENT NAME TELEPHONE NUMBER
OREGON REGISTERED AGENT MAILING ADDRESS CITY STATE ZIP CODE
OREGON REGISTERED AGENT STREET ADDRESS CITY STATE ZIP CODE
PRINCIPAL'S DEALER HISTORY
Information on the principals of this business is requested under Oregon Revised Statutes (ORS) 822.035 and Oregon
Administrative Rule (OAR) 735-150-0024.
OAR 735-150-0010(28) defines the principal of a dealership as "an owner, partner, corporate officer or other person who
controls or manages the business organization or employees or agents of the business organization." "Principal"
includes all owners, partners, members, corporate officers, or directors.
Please provide the following information about all owners listed on this application and other principal(s) of the
business:
Has any principal of this dealership been financially or operationally involved in any jurisdiction, including Oregon,
with a vehicle dealership whose certificate or right to apply for a certificate was revoked or is currently suspended?
[$kqO ❑ YES, revoked or is currently suspended. If "YES," complete Section 19.
NAME OF DEALERSHIP PRINCIPAL'S NAME(S)
DEALER CERTIFICATE NUMBER STATE WHERE SUSPENDED / REVOKED DATE OF SUSPENSION / REVOCATION EXPIRATION OF SUSPENSION
Has any applicant ever been an owner or principal on a vehicle dealer certificate in Oregon (excluding current application)?
JLN0 ❑ YES: If "YES," complete Section 21.
NAME OF DEALERSHIP PRINCIPAL'S NAME(S)
DEALER CERTIFICATE NUMBER
OWNER INFORMATION AND CERTIFICATION
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 against you or your dealer certificate may be imposed.
With this in mind ...
I CERTIFY ...
• I am an owner, a partner, limited liability company member or corporate officer of this dealership and my name is
listed on this application.
• ALL information on this application is accurate and complete.
• 1 deal in vehicles and conduct business at the location given on Line 3 of this application.
• The dealership will comply with all applicable laws and administrative rules.
• I/we hereby certify that the persons named in this application are not acting as the alter ego, in the place of, or on
behalf of, any other person or persons in seeking this certificate.
735-370 [2-231_J
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DMV AGENT AGREEMENT
The dealer is granted the following options as a DMV agent and must comply with all applicable
laws and administrative rules. The dealer is not obligated to perform any of these options except
as required by law. *Snowmobile dealers must act as DMV agents for Oregon residents.
• *Accept applications and fees for titles and registrations of vehicles they sell, and only charge fee
amounts set by Oregon Revised Statutes (ORS) and Oregon Administrative Rules (OAR).
• Perform vehicle identification number inspections on vehicles they sell, except a dealer may not
perform an inspection under those situations described in OAR 735 -022 -0070(6)(A -G).
• Issue temporary registration permits for unregistered vehicles they sell.
• Agent status can be placed on probation, suspension or revoked as allowed in OAR 735-150-0120
for non-compliance of any ORS of the Oregon Vehicle Code.
• By signing this application on Page 3, the dealer becomes an agent of DMV and agrees to comply
with all administrative rules and all dealer related statutes in the Oregon Vehicle Code.
OWNERSHIP INFORMATION
PRINT NAME OF OWNER, PARTNER, LLC MEMBER OR CORPORATE OFFICER TITLE TELEPHONE
(NUMBER
DATE OF BIRTH DRIVER LICENSE NUMBER STATE OF ISSUANCE EMAIL
RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP CODE
CERTIFYING SIGNATURE OF OWNER SHOWN ON LINE 22 ABOVE DATE
X
PRINT NAME OF OWNER, PARTNER, LLC MEMBER OR CORPORATE OFFICER TITLE
TELEPHONE NUMBER
DATE OF BIRTH
DRIVER LICENSE NUMBER
STATE OF ISSUANCE
EMAIL
RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP CODE
CERTIFYING SIGNATURE OF OWNER SHOWN ON LINE 27 ABOVE DATE
X
PRINT NAME OF OWNER, PARTNER, LLC MEMBER OR CORPORATE OFFICER
TITLE
TELEPHONE NUMBER
DATE OF BIRTH
DRIVER LICENSE NUMBER
STATE OF ISSUANCE
EMAIL
RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP CODE
CERTIFYING SIGNATURE OF OWNER SHOWN ON LINE 32 ABOVE
DATE
X
PRINT NAME OF OWNER, PARTNER, LLC MEMBER OR CORPORATE OFFICER TITLE TELEPHONE NUMBER
DATE OF BIRTH DRIVER LICENSE NUMBER
STATE OF ISSUANCE
EMAIL
RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP CODE
CERTIFYING SIGNATURE OF OWNER SHOWN ON LINE 37 ABOVE
DATE
X
E 735-370 P-23)
Page 3 (Over for Photo ID...)
42
Please attach copies of ALL owners, partners, LLC members or corporate officers valid
government photo ID's. If the residence address on the photo ID is different than the
residence address listed on Page 3, submit a statement explaining why the addresses do
not match.
Copy must be legible.
Submit fees and these items to DMV together:
• Application (Form 735-370)
• Bond (Form 735-370B)
• Certification of Liability Insurance (Form 735-370B) or Certification of Exemption (Form
735-7024)
• Billing List (renewals only)
• Supplemental Application (if more than one location) (Form 735-372)
• Certificate of education completion or Certification of Exemption from Dealer Education
Requirements (Form 735-370C).
• Request for DMV location requirement exemption if applicable.
• Copies of ALL owners, partners, LLC members or corporate officers valid government -
issued photo ID's.
To: DMV Business Licensing Unit Phone: (503) 945-5052
1905 Lana Ave NE Business office hours are: 8:00 a.m. — 4:30 p.m. Monday —
Salem OR 97314 Friday, except for Thursdays 9 a.m. — 4:30 p.m., (closed
holidays).
"n, Um Pane 4
SURETY BOND
NOTE: TO BE COMPLETED BY BONDING COMPANY. FAILURE TO
OFRMR3lf
AROF TRANSPORTATION ACCURATELY COMPLETE THIS FORM WILL CAUSE DELAY.
OAFM ANO MOTOR VEHICLE SERVILE.4
IM LANA AVE NE, SA" OREGON M14 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 GiYEN ON THE CERTIFICATE APPLICATION)
HAVING ITS PRINCIPAL PLACE OF BUSINESS AT
(STREET ADDRESS, CITY, STATE, ZIP CODE)
:A.
WITH ADDITIONAL PLACES OF BUSINESS AT _
(STREET ADDRESS, CITY, STATE, ZIP CODE)
(STREET ADDRESS, CITY, STATE, ZIP CODE)
AS PRINCIPAL(S), AND
(SURETY NAME) r 1
(ADDRESS, CITY, STATE, ZIP CODE) (TELEPHONE NUMBER)
A CORPORATION ORGANIZED AND EXISTING UNDER AND 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 TO THE STATE OF OREGON IN THE PENAL SUM OF $50,000 FOR EACH YEAR THE CERTIFICATE IS VALID, FOR THE
PAYMENT OF WHICH THE PRINCIPAL(S) AND SURETY JOINTLY AND SEVERALLY BIND THEMSELVES, THEIR RESPECTIVE
SUCCESSORS, AND ASSIGNS. THE MAXIMUM AMOUNT PAYABLE UNDER THE BOND FOR PAYMENT OF CLAIMS BY PERSONS
OTHER THAN RETAIL CUSTOMERS OF THE VEHICLE IS $10,000.
WHEREAS, THE PRINCIPAL(S) IS APPLYING FOR A VEHICLE DEALER CERTIFICATE ISSUED BY THE OREGON DEPARTMENT OF
TRANSPORTATION;
THE CONDITION OF THIS OBLIGATION IS SUCH THAT WHEN THE ABOVE NAMED PRINCIPAL(S) IS ISSUED A VEHICLE DEALER
CERTIFICATE TO CONDUCT, IN THIS STATE, A BUSINESS AS A DEALER OR REBUILDER OF VEHICLES, SAID PRINCIPAL(S)
SHALL CONDUCT SUCH BUSINESS WITHOUT FRAUD OR FRAUDULENT REPRESENTATION, AND WITHOUT VIOLATION OF ANY
OF THE PROVISIONS OF THE OREGON VEHICLE CODE SPECIFIED IN ORS 822.030(2), THEN AND IN THAT EVENT THIS
OBLIGATION TO BE VOID, OTHERWISE TO REMAIN IN FULL FORCE AND EFFECT UNLESS CANCELLED PURSUANT TO ORS
822.030(1)(a).
THIS BOND SHALL BECOME EFFECTIVE AS OF THE DATE THE PRINCIPAL(S) IS ISSUED A VEHICLE DEALER CERTIFICATE BY
THE OREGON DEPARTMENT OF TRANSPORTATION. THIS BOND SHALL BE DEEMED CONTINUOUS IN FORM AND REMAIN IN
EFFECT FOR THE ENTIRE PERIOD FOR WHICH CERTIFICATION IS GRANTED AND FOR EACH SUCCEEDING CERTIFICATION
PERIOD UPON RENEWAL OF THE VEH CLE DEALER CERTIFICATE, 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 BE ONE CONTINUING 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 BEYOND THE ORIGINAL CERTIFICATION PERIOD, IRRESPECTIVE OF THE NUMBER OF YEARS IT IS IN EFFECT.
THIS BOND IS EFFECTIVE
(MONTH, DAY, YEAR)
-- ANY ALTERATION VOIDS THIS BOND --
IN WITNESS WHEREOF, THE SAID PRINCIPAL(S) AND SAID SURETY HAVE EACH EXECUTED THIS BOND BY ITS AUTHORIZED
REPRESENTATIVE(S) AND HAVE AFFIXED THE SURETY CORPORATE SEAL HEREUNTO
THIS DAY OF
(DAY) (MONTH) (YEAR)
SIGNATURE MWNEHIPARTNE"EMBER OR CORPORATE OFFICER) TITLE
X
SIGNATURE OF SURETY (AUTHORIZED REPRESENTATIVE)
TITLE
X
SURETY SEAL BELOW
I
SURETY'S AGENT OR REPRESENTATIVE MUST COMPLETE THIS SECTION:PLACE
IN THE EVENT A PROBLEM ARISES CONCERNING THIS BOND, CONTACT:
NAME
TELEPHONE NUMBER
ADDRESS
CITY, STATE, ZIP CODE
APPROVED BY ATTORNEY GENERAL'S OFFICE
CERTIFICATE OF INSURANCE
TO BE COMPLETED BY INSURANCE COMPANY LICENSED TO DO BUSINESS IN OREGON
INSURANCE POLICY NUMBER (BINDER NOT ACCEPTABLE)
EFFECTIVE DATE -T
EXPIRATION DATE
INSURANCE COMPANY NAME AND ADDRESS (NOT AGENT)
INSURANCE COMPANY PHONE NUMBER
AGENT NAME AND ADDRESS
CITY, STATE, ZIP CODE
THIS POLICY IS ISSUED TO (REGISTERED BUSINESS NAME OF DEALER, PARTNERS, OR CORPORATION NAME)
BUSINESS NAME OF DEALERSHIP (DBA)
DEALERSHIP ADDRESS DEALER NUMBER
I CERTIFY THAT THE FOLLOWING IS TRUE AND CORRECT. The above described policy has been issued
and provides liability limits of coverage required under ORS 806.070; provides for payment of judgments of the
type described in ORS 806.040; covers all motor vehicles manufactured, owned, operated, used or maintained
by, or under the control of the named insured; covers all persons who, with the consent of the named insured,
use or operate motor vehicles manufactured, owned or maintained by, or under the control of, the named insured;
the insurer shall give written notice of any cancellation of the policy to DMV Business Licensing Unit; the
insurer shall continue to be liable under the policy until DMV receives the notice of cancellation or until the
cancellation date specified in the notice, whichever is later.
It is a crime under ORS 162.085 to certify the truth of a statement when you know it is not true. Such a crime is a
Class B misdemeanor and is punishable by a jail sentence of up to six months, a fine of up to $2,500 or both.
SUPPLEMENTAL DEALERSHIP ADDRESS
CITY, STATE, ZIP CODE
SUPPLEMENTAL DEALERSHIP ADDRESS
CITY, STATE, ZIP CODE
PRINT NAME OF INSURER'S AUTHORIZED REPRESENTATIVE
TELEPHONE NUMBER DATE
SIGNATURE OF INSURER'S AUTHORIZED REPRESENTATIVE
INSURER'S ADDRESS STAMP OR SEAL (If no stamp attach a business cans)
X
DEALER LIABILITY INSURANCE
General Information
WHAT IS NEEDED: ORS 822.033 requires a dealer to carry vehicle liability insurance coverage for their
dealership. A Certificate of Insurance must be filed with the Business Licensing Unit each time a dealer applies for
a new or renewal business certificate, or when the certificate on file is expired in order to provide continuous coverage.
AMOUNTS OF COVERAGE: ORS 806.070 requires the policy to provide coverage in specific amounts and
ORS 806.040 requires the policy to provide for the payment of judgments.
ADDITIONAL STIPULATIONS: ORS 822.033 requires that the coverage provide each of the following:
* The policy must cover ALL MOTOR VEHICLES manufactured, owned, operated, used or maintained by,
olunder the control of the named insured.
e The policy must cover ALL PERSONS who, with the consent of the named insured, use or operate motor
vehicles manufactured, owned or maintained by, or under the control of, the named insured.
e The insurer must give written notice of ANY CANCELLATION of the policy to the Business Licensing Unit.
The insurer shall CONTINUE TO BE LIABLE under the policy until the Business Licensing Unit receives
the notice of cancellation or until the cancellation date specified in the notice, whichever is later.
(Note: This means that even if the policy expires and is not renewed, the insurer continues to be liable
until the Business Licensing Unit receives a notice of cancellation.)
TERM OF COVERAGE. The dealer must maintain coverage throughout the license period covered by
their business certificate. If the policy lapses for any reason, the dealer must file a new Certificate of
Insurance providing continuous coverage with the Business Licensing Unit.
EXEMPTION: ORS 822.033(3) states a dealer is exempt from the requirement to file a Certificate of Insurance if
they deal exclusively in certain types of vehicles. To get the exemption, a dealer must file a Certificate of
Exemption, Form 735-7024. To request a Form 735-7024, call DMV Business Licensing Unit at (503) 945-5052.
All Certificates of Exemption are subject to approval upon review by the Business Licensing Unit.
1735-370B (10-22) 1