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HomeMy WebLinkAboutApplication Applicant 4/3/2024City of Springfield SPRINGFIELD - Development & Public Works 225 Fifth Street Springfield, OR 97477 im, I Lh *Wq LAND USE COMPATIBILIITY STATEMENT (LUCS), DEPARTMENT OF MOTOR VEHICLES (DMV) and ZONING VERIFICATION LETTER Application form VG'.I� %P. %F VI �Gl.l%.. i-..7-1\%.1111. LJ LQ..Y wmG 6.V.I1�JQ L1 YIl.Lr JLp LGIIIGIIL. LJ �.ILr. ,J 1Dept of Motor Vehicles -Renewal: El Zoning Verification Letter: ElUGB: ElF Project Applicant Name: .! 59S 7 1 Phone: 5-6112.32 2 2 3 2 Company: Zoa d -c E-mail: && ff5,Tdw,n ,Address: &2-5 -5 2— _5_'t 5,�i�t L17� Property Owner: i Phone:51// 51j " "�S q K Company: ✓1 f-.,> E-mail: Address: �Z+ Z Sfi I '77Z,17 ASSESSOR'S MAP NO: TAX LOT NOS : Property Address: Description of proposal/ request: Recordation (Staff to I ).. Record No: `�1-�r VV��� Date Received: Applica_tion Fee: $ 31b S. DD TOTAL FEES: $ Technical Fee: $ tS . Assigned Planner: L Revised 2023 04 04 slm 1 2 3 4 5 6 7 8 91 APPLICATION FOR CERTIFICATE NUMBER ANNUAL BUSINESS CERTIFICATE EFFECTIVE DATE DEPARTMENT OP TRANSPORTATION AS A DISMANTLER OF MOTOR VEHICLES OR DRIVER AND MOTOR VEHICLE SERVICES 18D5 LANA AVE NE, SALEM OREGON 87314 SALVAGE POOL OPERATOR FEE:$500 EXPIRATION DATE 41 PLEASE TYPE OR PRINT LEGIBLY WITH INK. El ORIGINAL —]RENEWAL 'B' ANY ALTERATION OF LINE 3 VOIDS LOCATION APPROVAL( LEGAL NAME OF APPLICANT (OWNER, PARTNERSHIP, LLC OR CORPORATION NAME) FEDERAL EMPLOYEE ID NUMBER (FEIN) k- g3-C�irlp(?D78 OREGON REGISTRY NUMBER (IF LLC OR CORPORATION) 1�1$(�r�-`� I.IStkrl M�Ck6LZ1 ( BUSINESS NAME OF APPLICANT (IF ASSUMED BUSINESS NAME OR TRADE NAME)O�REGON groolts REGISTRY NUMBER BUSINESS TELEPHONE (IF USING ASSUMED BUSINESS NAME OR TRADE NAME) (59 1) (003 W T LjZK ci-04"IZ eAcl RE LLC - g7 MAIN BUSINESS LOCATION (STREET AND NUMBER) `$ 2-5 5 -�- CITY - S .r :�� e.l d ZIP CODE 9-7q7 7 COUNTY L a- n f, MAILING ADDRESS CITY STATE ZIP CODE BUSINE33 EMAIL id 012 `f7�i77 8r-40-0 . io:J® h�® CHECK ORGANIZATION TYPE: If corporation, list the state where Individual ❑ Partnership VKLLC ❑ Corporation: the business is incorporated: +OREGON REGISTERED AGENT NAME TELEPHONE NUMBER ()UI'D k►n MIcV%CLe 1 (5'qi 23a -..a3 _F2 OREGON REGISTERED AGENT STREET ADDRESS CITY STATE ZIP CODE 15go 5 -,-> ± r,k(P.-eJci 0� 9i'y77 OREGON REGISTERED AGENT MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE National Motor Vehicle Title Information System (NMVTIS) number REQUIRED: 10 a) THE DIMENSIONS OF THE PROPERTY ON WHICH THE BUSINESS HAS EXCLUSIVE USE ARE ft. X ft. b) 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, including identification of the area of the property exclusively used by the dismantler business (if not the entire property). 11 ! 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 population of 100,000 or more. By signing on Line 13, 1 certify that pursuant to ORS 822.110(1)(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: THAT THE GOVERNING BODY OF THE ❑ CITY OF HAS: ❑ COUNTY 12 A) APPROVED THE APPLICANT AS BEING SUITABLE TO ESTABLISH, 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. ❑ Restrictions on the location approval are in an attached letter from the zoning authority. ♦ PLACE STAMP OR SEAL HERE 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. NAME OF GOVERNMENT OFFICIAL 'TITLE PHONE NUMBER TORE OF GOVERNMENT OFFICIAL 131x Page 1 DATE 14 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: 1 rJ 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? ® NO ❑ YES, revoked currently suspended. if "YES," complete Section 16. 16 NAME OF DISMANTLER BUSINESS PRINCIPAL'S NAME DISMANTLER CERTIFICATE NUMBER STATE WHERE SUSPENDED / REVOKED DATE OF SUSPENSION / REVOCATION EXPIRATION OF SUSPENSION 17 Have you ever been an owner or principal on a vehicle dismantler certificate in Oregon (excluding current application)? D� NO ❑ YES: If "YES," complete Section 18. 18 NAME OF DISMANTLER BUSINESS PRINCIPAL'S NAME DISMANTLER CERTIFICATE NUMBER BUSINESS LOCATION INFORMATION: 19 Property is (check one): ❑ OWNED © LEASED / RENTED: LEASE OR RENTAL PERIOD: Yea I - If property is "Leased / Rented" complete the following: 20 PROPERTY OWNER'S FULL NAME (As shown on Property County Records) TELEPHONE NUMBER L I(jy I) 5q3-&5'9? 21 PROPERTY OWNER'S MAILING ADDRESS CITY STATE ZIP CODE f c?&Io4 C:� den VO.ilevr t-uaerie dregon 197L105 APPLICANT: By signing this application you are certifying that: 1. 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 against you or your dismantler certificate may be imposed. I certify that I am the owner, a partner, an LLC member, or a corporate officer 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. Page 2 GI 24 2! A 2, 2f 2E V 3C 31 32 '33 34 35 36 OWNERSHIP INFORMATION PRINT NAME OF OWNER/ PARTNER / LLC MEMBER /CORPORATE OFFICER TITLE TELEPHONE NUMBER < I .2 DATE OF BIRTH DRIVER LICENSE NUMBER STATE OF ISSUANCE EMAIL %►n6i lj,,a a I �L - DIV- 19 IkI, 733 U2 1 3 Or' .1 a 6rdci�st�us - CITY STATE 1 ZIP CODE C?`7V -77 RESIDENCE ADDRESS t 54C) 3 S 0R- MAILING ADDRESS (IF DIFFERENT) 1 CnY STATE ZIP CODE CERTIFY!SIGNATURE OF PRINCIPAL SHOWN O LINE 22 ABOVE DATE PRINT NAME OF OWNER / PARTNER / LLC MEMBERLE / CORPORATE OFFICER TIT TELEPHONE NUMBER DATE OF BIRTH DRIVER LICENSE NUMBER STATE OF ISSUANCE EMAIL RESIDENCE ADDRESS I CITY STATE ZIP CODE 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 TITLE TELEPHONE NUMBER DATE OF BIRTH DRIVER LICENSE NUMBER STATE OF ISSUANCE EMAIL RESIDENCE ADDRESS CITY STATE ZIP CODE RES MAILING ADDS (IF DIFFERENT) CITY STATE ZIP CODE CERTIFYING SIGNATURE OF PRINCIPAL SHOWN ON LINE 32 ABOVE DATE X S7 Are there any applicable permits required by Oregon Department of Environmental Quality (DEQ)? ® NO ❑ YES: If "YES," complete Section 38. 38 DEQ PERMIT TITLE / NUMBER(S) DATE OF ISSUE -FDATE OF EXPIRATION REQUIREMENTS PERTAINING TO DISMANTLER BUSINESS OR PREMISES (ATTACH A SEPARATE PAGE FOR DESCRIPTION AND/OR ADDITIONAL PERMITS IF I - - Attach (staple) copies of ALL owners, partners, LLC members or corporate officers' valid government photo 39 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. Copy must be legible. 40 Fire Response Plan Required - Attach a fire response plan as described in the instructions. 41 Fire Inspection Report Required: - Attach a copy of the fire inspector's report which is based on an inspection of the business premises. New and renewing dismantler applications must provide a fire inspection report within 90 days after being issued an original or renewed dismantler certificate. A fire inspection report must be submitted for all approved business locations - main and supplemental locations. Page 3 Poll - -- - APPLICATION FOR THREE YEAR VEHICLE DEALER CERTIFICATE DFMWMEM q m MMWAT a u� f �;, AS A DEALER OR REBUILDER OF VEHICLES USTOMER NUMBER EFFECTIVE FATE I EXPIRATION IDATE I DEALER NUMBER ❑ 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. Original Certificate (Includes one plate) ................................. $1,188.00 Additional Locations - _ __ . @$350.00 ..................... $ 0.00 (Supplemental Application Form 735-372 required for each location) $ 0.00 Additional plates 12" x 6" or 7" x 4" $55.00... (Two sizes, standard and small, available) TOTAL = $ 1,188:00 ORIGINAL ❑ RENEWAL �" � tEMA41FtY7�'S . BUSINESS NAME AND ADDRESS Any alteration of Line 3 voids location approval. LEGAL NAME OF APPLICANT (0 ER, PARTNERSHIP, LLC OR CORPORATION NAME) FEDERAL UMBER (FEIN) OREGON REGISTRY # (IF LLC OR CORPORATION) 1 Brook VseT JA SCLeS _ F$-xID N7929 So 9 I9 139793 BUSINESS NAME (IF ASSUMED BUSINESS NAME, FILL IN REGISTRY NO.) OREGON REGISTRY NO. BUSINESS TELEPHONE 2 MAIN BUSINESS LOCATiON,(,STREET AND NUMBER) 3� S :S (a$ S;}- CITY $ r -i n ,' 1 ZIP CODE 9-7q7 7 COUNTY L o n ew4 MAILIG ADDRESS CITY SP STATE ZIP CODE ?w 76rK EMAIL a9 D - Y Go nt TYPE OF OPERATION If corporation, list the state under 6CHECK ORGANIZATION TYPE: ❑ which business is incorporated: Individual ❑ Partnership LLC ❑ Corporation: 6 I /we primarily sell: ❑ New Vehicles [D Used Vehicles 7 I / we area franchise dealer: ❑ Yes [D No If -"Yes," name the makes )k- 8 I / we sell NEW RECREATIONAL VEHICLES: ❑ Yes [A 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. 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 np(ies with any land use ordinances of the jurisdiction pursuant to ORS 822.025. 9 ❑ CITY OF: ❑ COUNTY OF: PRINT NAME 10 SIGNATURE 11 X I ❑ Check box if restrictions on the location approval are in an attached letter from the zoning authority. Page I TELEPHONE NUMBER TITLE DATE 17 Race stamp or sed here � 1i 1� 1� 15 if. 11 16 Ir. 20 21 BUSINESS LOCATION INFORMATION: Property is (check one): ❑ OWNED LEASED/ RENTED: LEASE OR RENTAL PERIOD: S If property is "Leased / Rented" complete the following: PROPERTY OWNER'S FULL NAME (As shown on County Property Records) TELEPHONE NUMBER S D L acv �rv>L -s f) 57L/3 b 5 g y �/ v5 e A4 5`1 PROPERTY OWNER'S MAILING ADDRESS CITY STATE ZIP CODE 3 (o I O CI Gard -e.^ yo-49AA 1E Q, e.rz 0 re -c (Be sure to attach a separate sheet to show additional owners.) • List the primary owner, partners, LLC members or corporate officers. • If 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 Z U,�-; cook 5qa3a-x232 OREGON REGISTERED AGE0 �NMAILING ADDRESS CITY �r[ STATE ZICODE 5 r' n � / 2 OREGOON' 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? NO ❑ YES, revoked or is currently suspended. If "YES," complete Section 19. NAME OF DEALERSHIP PRINCIPAL'S NAME(S) DEALER CERTIFICATE NUMBER ISTATE WHERE SUSPENDED I 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)? ® NO —1 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 ... • 1 am an owner, a partner, limited liability company member or corporate officer of this dealership and my name is listed on this application. 10 ALL information on this application is accurate and complete. 0 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. 1735-37011-24) Page z 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 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 (QRS) 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 ne_ R3J-2PL3 DATE OF BIRTH �, _ ? t i DRIVER LICENSE NUMBER _1 � STATE OF ISSUANCE EMAIL �l�k�G� Bcaok-sC>L78 1`n�% I " 113 cireearl C-0ax RESIDENCE ADDRESS CITY STATE ZIP CODE MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE CERTIF SIGNATURE OF OWNER SHOWN ON LINE 22 ABOVE DATE X q -4 - zy : 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 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. Kr. �S36If3 CfLiAFK'H.�FL i 54� S ST SPFONGFIELD. OR t-W- "ae�q .. •' zrr .iasib rC7109[ '`w� a S2 U I ;z�4µ ua� - • �= �-'tea - Submit fees and these items to DMV together: • Application (Form 735-370) • Bond (Form 735-3708) • 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). mw ■ Page 4 EDUCATION REQUIREMENTS -EPARTMENT OF MOTOR REHICLETATION CERTIFICATION OF EXEMPTION ONIVEit AND MOTOR VEHICLE BEHYICEB j YOB LANA AVE NE, BAUM OREGON 07314 NUMBER INSTRUCTIONS: • Renewal applications may qualify for an exemption from dealer education. All certificates of exemption are reviewed by DMV for acceptability. • This form must be submitted with an Application for a Dealer Business Certificate. • This form must be completed by an owner, partner, LLC member or corporate officer of the dealership. • Mark the box below to show the type of exemption sought. • Read and sign the certification statement at the bottom of this form. • Submit this exemption along with your application for a dealer certificate to: Business Licensing Unit, 1905 Lana Avenue NE, Salem OR 97314. Telephone: (503) 945-5052. 9USINE5S NAME OF UEAL£RSHIP "BrOO KS U MAIN BUSYNESS LOCATION s 2(01- >e.d Au�-o LLC a+ - ITY ZIP CODE 15r� �`e�/c 9.7 4.7 7 The education requirements do not apply to an applicant for a vehicle dealer certificate under ORS 822.020 or 822.040 if the applicant is one of the dealers listed below and have a current or is renewing a dealer certificate. I understand that if I sell or otherwise act as a vehicle dealer regarding any type of vehicle other than those listed below, I must file the appropriate certificate of education* with the DMV Business Licensing Unit: * Note: All original applications (including franchises) require a preliminary 8 hour dealer education certificate unless an applicant has a certificate with a currently certified Oregon dealer. ❑ A franchised dealer in Oregon for nationally advertised new vehicles. ❑ A franchised dealer in Oregon for nationally advertised new recreational vehicles. ❑ A vehicle rental company with a nationally advertised franchise under the ownership of a corporation that operates nationwide. ❑ A national auction company that holds dealer and dismantler certifications and sells totaled vehicles. ❑ Applicant for original certificate holds a precertification education certificate from a current, certified Oregon dealer. List affiliated dealer name and number: CERTIFICATION False statement 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 of up to $1,000 and DMV sanctions against you or your dealer certificate may be imposed. With these penalties in mind, I CERTIFY I am an owner, partner, LLC member or corporate officer of this dealership and all information on this Certificate of Exemption is true and correct. PRINT NAME OF CERTIFYING OWNER / PARTNER / CORPORATE OFFICER / LLC MEMBER TITLE Bron Ks Used Mv+o S(,(e,3 0 w n yr SIGNAEOF CERTIFYING ERER /CORPORATE OFFICER/ LLC MEM DATE _ - 93 L3 SURETY BOND BOND NUMBER NOTE: TO BE COMPLETED BY BONDING COMPANY. FAILURE TO nON OEPAVER TMENT OF AND VEHICLEG RVIC ACCURATELY COMPLETE THIS FORM WILL CAUSE DELAY. DRIVER AND MOTOR VEHICLE 6EflY10ES 199E LANA AVE NE, SALEM OREGON 97314 PLEASE TYPE OR PRINT LEGIBLY WITH INK. LET 1T BE KNOWN: * i7s THAT. (INDIVIDUAL NAME OF OWNER, ALL PARTNERS OR MEMBERS, OR NAME OF CORPORATION) DOING BUSINESS AS (BUSINESS,NgAME AS GIVEN ON THE CERTIFICATE APPLICATION) HAVING ITS PRINCIPAL PLACE OF BUSINESS AT (STREET ADDRESS, CITY, STATE, ZIP CODE) WITH ADDITIONAL PLACES OF BUSINESS AT (STREET ADDRESS, CITY, STATE, ZIP CODE) (STREET ADDRESS, CITY, STATE, ZIP CODE) AS PRINCIPAL(S), AND Vow (SURETY NAME) - - ---- (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 w (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 (OWNERIPARTNER/MEMBER 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 TELEPHONE NUMBER ADDRESS CITY, STATE, ZIP CODE IE@Fff� 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 EXPIRATION DATE I INSURANCE COMPANY NAME AND ADDRESS (NOT AGENT) INSURANCE COMPANY PHONE NUMBER l / _ 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 card) 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: 0 The policy must cover ALL MOTOR VEHICLES manufactured, owned, operated, used or maintained by, orunder the control of the named insured. 0 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. 0 The insurer must give written notice of ANY CANCELLATION of the policy to the Business Licensing Unit. 6 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. 735.3nyf saw] REQUEST FOR DMV LOCATION REQUIREMENT EXEMPTION DEPARTMENT OF TRANSPORTATION DRIVER AND MOTOR VEHICLE SE7MCES (OAR 735-150-0030) 7806 LANA AVE NE, SALEM OREGON 87814 DEALER CERTIFICATE # EXPIRATION DATE i INSTRUCTIONS Pursuant to OAR 735-150-0030 (2), DMV is only authorized to grant exemptions for restrictions based on ordinance or zoning requirements. All other requests will be denied. Complete (print or type) and submit to: Business Regulation, 1905 Lana Ave NE, Salem OR 97314. A DMV Investigator or manager will review your request. A signed copy of the request will be returned to you. An approved request must be kept at your business location. Failure to do so may subject you to a civil penalty or administrative sanction. Approved exemptions are valid only for the dealer certificate number and location listed. A new exemption must be applied for if there is a change in name, address or dealer certificate number. - SECTION NAME AND LOCATION • BUSINESS DEALER CERTIFICATE # EMAIL ADDRESS NAME OF DEALERSHIP STREET ADDRESS (BUSINESS LOCATION) CITY STATE ZIP CODE COUNTY SECTION' • Any dealer wanting an exemption from all or part of the requirements in (a) through (c) below MUST check the appropriate box(es) below and provide a clear and complete reason for the request. I am requesting an exemption from the requirement(s) listed below: ❑ a) Have sufficient space to display one or more vehicles of the type the dealer has been issued a certificate to sell. ❑ b) Provide a means for the public to contact the dealer or an employee of the dealer at all times during the dealer's normal business hours. ❑ C) Have displayed an exterior sign permanently affixed to the land or building which identifies the dealership by the name shown on the dealer's business certificate. NOTE: You MUST attach to this form a letter or other evidence from the appropriate zoning authority which specifically and clearly show the restriction the exemption request is based on. SIGNATURE certify that I am an owner, a partner, a member of LLC or a corporate officer of this dealership. I understand that Oregon Administrative Rules require a dealer business location to comply with each of the three conditions listed above. However, the business location of the dealership, as shown in Section1, is unable to meet the requirements. Copies of city or county ordinances or zoning requirements preventing compliance are attached. I hereby request the exemptions marked in Section 2. NOTE: This exemption does not constitute a variance on state, county or city land -use restrictions or laws. Violation of zoning laws/restrictions could result in cancellation of your dealer certificate. PRINTED NAME OF PERSON SIGNING THIS FORM TITLE SIGNATURE f DATE X Only)(DMV Use Request in Section 2: a)❑Approved [—]Denied b)❑Approved ❑Denied c)❑Approved ❑Denied (Investigator to check all applicable boxes). If applicable, the dealer must comply with reasonable alternatives (attached). �PRIIJ NAME OF INVESTiisA'COR /MANAGEE2 ?ITLE IfNVESTIGi4TR'S / MAMA(�EWS SIGMA I1i131 DATE 735-7178 (12-20) 1 ■ LIABILITY INSURANCE OEPANTMENTOFlVEHOESEWON CERTIFICATION OF EXEMPTION 6LNAN0MHE, SAi M0H 00NW31 .6 LANA AVE HE, epI.EM ONEOON 9)916 _ALER NUMBER I EXPIRATION DATE INSTRUCTIONS: ■ You may qualify for an exemption from liability insurance if you deal exclusively in certain types of vehicles. All certificates of exemption are reviewed by DMV for acceptability. • This form must be submitted with an Application for a Dealer Business Certificate. ■ This form must be completed by an owner, partner, LLC member or corporate officer of the dealership. * Mark the box to show the type of vehicle you sell exclusively. Dealer plates will not be issued to you if you sell antique vehicles. * Read and sign the certification statement at the bottom of this form. ■ Submit this exemption along with your application for a dealer certificate to: Business Licensing Unit, 1905 Lana Avenue NE, Salem OR 97314. Telephone: (503) 945-5052. AIN BUSINESS LOCATION CITY 21P CODE This business deals exclusively in the vehicle types which I have marked below. I understand that if I sell or otherwise act as a vehicle dealer regarding any type of vehicle other than those listed below, I must file a Certificate of Insurance with the Business Licensing Unit. ❑ Antique motor vehicles which have been issued permanent registration under ORS 805.010 ❑ Class I or Class III all terrain vehicles (ATVs) ❑ Snowmobiles ❑ Trailers (utility, horse, boat) ❑ Campers and Travel Trailers CERTIFICATION False certificate of exemption from liability insurance 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, a civil penalty of up to $1,000 and DMV sanctions against you or your dealer certificate may be imposed. With these penalties in mind, I CERTIFY I am an owner, partner, LLC member or corporate officer of this dealership and all information on this Certificate of Exemption is true and correct. PRINT NAME OF CERTIFYING OWNER/PARTNER/CORPORATE OFFICER OF CERTIFYING OWNER/PARTNER/CORPORATE OFFICER DATE 'r OEPARTNENTOP', NSPORTAMN ORWERANO NOTOR VEHM E SERVICES JOW ANA AVE NE, MLEM OREGON 97M INSTRUCTIONS FOR COMPLETING AN ORIGINAL APPLICATION FOR THREE YEAR VEHICLE DEALER CERTIFICATE AS A DEALER OR REBUILDER OF VEHICLES OFFICE HOURS for Business Licensing Unit, in the Salem DMV Headquarters office, business hours are 8:00 a.m. — 4:30 p.m., Monday through Friday except Thursdays 9 a.m. — 4:30 p.m., (closed holidays). READ ALL PARTS of the application before completing it. Your application will be returned to you if any part is incomplete or missing. SUBMIT THESE ITEMS TOGETHER: ✓ YOUR COMPLETED APPLICATION (Be sure you provide copies of ALL owners, partners, LLC members or corporate officers official photo ID's) ✓ PLATE BILLING LIST (Renewal applications only) ✓ SURETY BOND (Must show original/wet signature of owner/partner/member) ✓ LIABILITY INSURANCE CERTIFICATE ✓ EDUCATION CERTIFICATE from a DMV approved provider or a CERTIFICATION OF EXEMPTION (Form 735-370C) ✓ FEES (Fees are itemized on the front of the application: use the plate billing list to renew) LEGAL NAME — If your business is a sole proprietorship, list your full nam is a partnership, list the full names of each partner or the partnership name. name of the limited liability company (includes "LLC") registered with the Registry. If your business is a corporation, list the name of the corporation the Business Registry (name search). MAIL TO: DMV BUSINESS LICENSING UNIT 1905 LANA AVE NE SALEM OR 97314 Phone: (603) 946-6062 Website: www.oregondmv.com e as the legal name. If your business If your business is an LLC, list the Oregon Secretary of State's Business (includes Inc, Corp, etc.) as shown in BUSINESS NAME — If using an assumed business name or trade name, list the business name registered with the Oregon Secretary of State's Corporation Division. If you do not know your Oregon Business Registry number(s), locate it in the Business Registry database, or contact Corporation Division at (503) 986-2200. Similar names NOT permitted. DMV will NOT issue or renew a certificate where the business name is identical or indistinguishable from an existing dealer name. See OAR 735-150-0027(6). FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) — Provide your FEIN, not your SSN. For more information go to www.IRS.gov. MAIN BUSINESS LOCATION — Write the address of your primary business location on Line 3. Your vehicles must be sold and displayed for sale at this location. Selling or displaying vehicles at a different location is a violation of ORS 822.040(2) and (3). If you change your business location, you must submit a correction application (Form 735-371) to DMV before you sell or display vehicles for sale at the new location. MAILING ADDRESS — All mail will go to the address on Line 4, except items which need a UPS -type delivery, such as trip permit and temporary permit books, as well as dealer plates, which will go to the business address on Line 3. SUPPLEMENTAL LOCATION USING THE SAME BUSINESS NAME — A separate supplemental application (Form 735-372) must be completed for each additional location where you operate your dealer business. You must conduct business at each supplemental location under the same name as the primary location. TYPE OF OPERATION — Complete all information on Lines 5 through 8. CITY/COUNTY LOCATION APPROVAL — Take your dealer application to the applicable city or county zoning, planning, or community development office to obtain their approval on Lines 9 through 11. Some cities and counties charge a fee for signing the application. Pursuant to ORS 822.025(6) you must get location approval on your original application. DMV DEALER LOCATION EXEMPTIONS — Each business location established by a dealer must: (1) have sufficient space to display one or more vehicles of the type the dealer has been issued a certificate to sell; (2) provide a means for the public to contact the dealer or an employee of the dealer at all times during the dealer's normal business hours; (3) display an exterior sign affixed to the land or building that identifies the dealership by the name; and (4) display, in a publicly conspicuous manner, the vehicle dealer certificate. Any dealer wanting an exemption from the requirements in (1) through (3) must complete a request for location requirement exemption Form 735-7178 (separate from city/county approval). There is no exemption permitted from (4) above. OWNERSHIP / APPLICANT'S CERTIFICATION SIGNATURE — Provide 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 listed on the application must provide a certifying signature. Attach copies of ALL owners, partners, LLC members or corporate officers valid Government -issued photo ID's to the application. (Continued on back...) PRINCIPAL'S DEALER HISTORY — Complete all information in this section. SURETY BOND— The bond form provided by DMV must be completed, signed and sealed by your bonding company. You must sign the bond, too. The owner name(s), legal and business name and business location must match the dealer application exactly. LIABILITY INSURANCE CERTIFICATION — The liability insurance certification form provided by DMV must be completed, signed and stamped by your insurance company. DMV will also accept an insurance company form furnished by the insurance company as long as it duplicates the DMV form. DMV does not accept "ACORD" forms or binders. The owner name(s), legal and business name and business location on the insurance certificate must match the dealer application exactly. DEALER EDUCATION — • Must submit education certificate from an approved provider or submit DMV Certificate of Exemption (Form 735-370% • Original Applicant needs 8 hours of education (check www.oregondmv.com Dealers & Businesses page for providers). • Renewal applicant needs 4 hours of education per year in a licensing period (12 hours continuing education for 3 - year certificate). • Must be completed by one of the applicants listed on page 3. CHANGING YOUR BUSINESS NAME — You must file a correction application (Form 735-371) with DMV before you conduct dealer business using a new name. The correction application must be signed by an owner and include: • a rider from your bonding company, and • a new certificate of insurance from your liability insurance company. • See correction application (Form 735-371) for fee. CHANGING YOUR BUSINESS LOCATION — If you move your dealership, you must file a correction application (Form 735-371) with DMV before you sell or display at a new location. The correction application must be signed by an owner and include: • location approval from the applicable city or county, • a rider from your bonding company, and • a new certificate of insurance from your liability insurance company. • See correction application (Form 735-371) for fee. CHANGING YOUR. BUSINESS NAME and LOCATION — You must file a correction application (Form 735-371) with DMV if you change your business name and location. The correction application must be signed by an owner and include: • a rider from your bonding company, and • a new certificate of insurance from your liability insurance company. OTHER CHANGES — You must file a correction application (Form 735-371) 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). The correction application must be signed by an owner (including all new owners being added or removed) and include: • See correction application (Form 735-371) for fee. SUPPLEMENTAL CERTIFICATE — You need a supplemental business certificate for each additional location where you conduct dealer 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 dealer business at the additional location. The supplemental application (Form 735-372) must be signed by an owner and include: • location approval from the city or county, and • See application for fees. DEALER PLATES — Dealer plates may only be used on vehicles owned or in sales inventory by the dealer, and in actual use by the dealer, members of the dealer's firm, any salesperson thereof or any person authorized by the dealer. Dealer plates may not be used on vehicles operated for commercial purposes. • To report a missing plate, submit information to: DMV Business Licensing Unit at 1905 Lana Ave NE, Salem OR 97314, or email dmvinsert@odot.oregon.gov. Specify the alpha numeric character of the missing plate (e.g., DA123A). • To purchase additional plate(s), submit Form 735-6938 and fee to: DMV Business Licensing Unit, 1905 Lana Ave NE, Salem OR 97314. If you have any questions please contact Business Licensing Unit at (503) 945-5052