HomeMy WebLinkAboutApplication APPLICANT 11/17/2011 City of Springfield SPRINGFIELD
Development Services Department
225 Fifth Street6
Springfield, OR 97477 V4, /
PERMIT REVIEW INTAKE FORM (City Staff completes form)
Permit Type
Dept of Motor Vehicles-New: ❑ Land Use Compatibility Statement: ❑ City:
V'1 Dept of Motor Vehicles-Renewal: Zoning Verification Letter: ❑ UGB: ❑
'Project Information
Applicant Name: y('I�r6l. Phone: 541 J -7'T� -!00I
Company: fI n I t p F U+0 �-�-1 t U Cell:
Address: , 010 rtti 6 rqAi e Id 12-- 41 y 17
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Property Owner: Ch(Arles arra I Phone: 5q I- �N ]` (Q
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Company: Cell:
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Address: Y • 0 • 60Y I Zl � � i (( 0P_ -7g7 -7
ASSESSOR'S MAP NO:
I / S I 0 0 >0 1 00TAX-I-LOT NOS : Q 100
Pro a - 1
Address: 5D So . � fY tti— nN e Id I o). JY7
Description of Proposal:
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,Record .
Record No: PpoAT11- 0 0 U I LI Date Received:
Application Fee: , 00 Technical Fee:
TOTAL FEES: $ Assigned Planner: Q/
Date Received:
NOV 17 2011
Ofiginal Submittal_.-----
Revised 11.2.11 kl
Ah W R2030
MV
C INSTRUCTIONS FOR CO LETING AN
APPLICATIONIFOR A DISMANTLER CERTIFICATE
(Originals and Renewals)
.w�u ac•i;wsv crcrav gym.
OFFICE HOURS for Business License Unit, in the Salem [SMV Headquarters office,
in person are 8:00 — 4:30 p.m., rJonday through Friday excluding holidays.
Read the entire application before completing it. This application Will be returned to you if
Fincomplete.
Submit your completed application and fees to:
DMV Business License Unit
1905 Lana Ave NE
SALEM OR 97314
Phone: 503-945-5052
IC Website: vmrro.oregondmv.com
When submitting your application and fees at the customer service counter:
• It paying in cash, please have correct amount since Business License Unit has no way to make change.
Make copies of your application for your records and Iopies of photo ID before you come to the counter.
Legal Name - if your business is a sole proprietorship, list your IUII name as the legal name. It your business is a
partnership, list the full names of each partner or the partnership name. If your business is an LLC, list the name of the
limited liability company{includes"LLC"} registered%v€th She Secretary of State Corporation Division. If your business is a
corporation, list the name of the corporation (includes: Inc, Corp, etc.) registered with The Secretary of State Corporation
I Division.
Business Name - if using an assumed business name or trade name, list the business name registered with The
Secretary of State Corporation Division.Othermse, your dismantler certificate%viii be issued using the legal name.
Oregon Registry Numbers - it you do not know your Oregon registry number(s): contact The Secretary of State
Corporation Division at 503.986-2200
4 Main Business Location-Business location v:here dismantling business is(or will be)being conducted.
k Type of Organization -Check y our organization type and if a corporation_ list the state under whose law the business is
incorporated.
Description of the location of the dismantling baslness —To verify compliance with ORS 822.115 and 822.135,
submit a plat map or other acceptable documentation that cieady shows compliance with all of these requirements. The
dimensions of the property on which the business is located is also required.
t Local Government Approval-An applicant must comply with any regulation established by a city or county under QRS
822.140 and must obtain the approval of the governing twdy of the city or county.Take this application to the applicable
citl or county office for their approval. Locol listings may be found in the phone book under `zoning,' land use" or
-permits." Some cines and counties charge a fee for signing the application.
Registered Agent- If your business is an LLC or a corp)ration. the registered agent's name, street address and mailing
address is required. Contact The Secretary of State Corporation Division for this information at 503-986-2200.
( Ownership/Applicant's Certification Signature-Provide the name, residence address, mailing address and signature
of owner. partners, LLC members or corporate officers on Page 2 (do not list CEOs. Chairs of the Board. General
Managers, Directors, etc.). Every applicant Listed on the application must provide a cerf€ying signature,
Photo ID - Staple copies of each applicant's official photo ID to this appfication. The copy must be fegible. If the
residence address on the photo ID and on Page 2 are not lthe same, attach a statement explaining why they do not match.
Bond - The bond required for a dismantler certificate is for 540,000 and must be completed, signed and sealed by your
bonding company. The owner, a partner, an LLC member.or a corporate officer must 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.
Supplemental Location Using the Same Business Name - A separate supplemental application (Form 735-373A)
must be completed for each additional location from which you operate dismantler business. You must conduct business
at each supplemental location under the same name as tie primary location. Date Received:
If you have any questions, please contact Business License Unit at (503)945.5052.
k NOV 17 2011
rns>ruc[ians
org
•nal submittal
. I • W R2030
CERTIFICATE NUf'6ER
APPLICATION FOR BUSINESS CERTIFICATE WR2030
AS A DISMAN T LER OF iv10TOR VEHICLES OR ( �FFf TIV�j
SALVAGE POOL OPERATOR ®I^ ff k
FEE: $450
O PLEASE TYPE OA PRUT LEGIBLY'NnH 6:tC.
•SEE PAGE 4 FOR INSiR'UCE043 FOR COUPLEi12.r:ADIEAf:hrLER A.PPLIC'ATION. I ORIGINAL II RENEWAL
•ANY ALTERATION OF LDIE 3 VOIDS LOCATION APPROVAL.
LEGAL SW E OF APPMCANT IO'NNE:,PA 7427 41P,LLC OR CORPORATION NAME] DREG�N,A=GISTRY NUMBER OP--1-C CCA CORFORAN CN)
1 SPRINGFIELD AUTO RECYCLERS INC I 1 011-7a:,Wo
IBL':JIESs NAME OF APPF.ICANT,IEA$SNMEi BDBWESS NAlIE DR rA0..ttARl_I j i.e 1:.f5Sa:.t• :ItWLF tmsf BlaINESS T_LEF'�OtIE
2; I I I ( ) (541) 747-9601
s}. I PLANE
IAIAIgNG ADDrt ESu, CITY 3TATE LP CODE
41 PO BOX 127 SPRINGFIELD OR 97477
l CHECK ORGANIZAaON TYPE
t If hose law business
fist the slats vodzt
51 Elndtvidual Partnership I?LLC JlCorporatlon: w�SPIa�,GDs111e55f41Y1forptt;,,a
I� a) THE DIMENSIONS OF THE PROPERTY ON WHICH THE BUSINESS IS LOCATED ARE j5l.zt.3 ft.X r h.
! b) OAS 822.115(4) requires applicants to file a description of the location of Tie dismantling yard. Accordingly,
} please file a plat map or other description of the location of the premises.
7j By signing this application you are also certifyingthaC
1. The right of way of any highway adjacent to the area proposed for approval to conduct the dismantling business is
used for access to the premises and public parking;
2. You maintain a building or enclosure or other barrier at least six feet high for the Purpase of conducting the
dismantling business; j
3. You will not store any vehicles or vehicle parte or conduct the dismantling business outside of the building,
enclosure or barrier;
4. The business is hidden and adequately screened by the terrain or other natural objects or by plants, fences or
other appropriate means so as not to be visible from the main traveled.vay or the highway except as permitted by
i ORS 822.135. I }
81 LOCAL GOVERNMENT APPROVAL(CITY/COUNTY)
By signing this application you are authorizing a dismanHer business to be conducted w the location listed an Line 3 of this
appiicanon. If a dismantler business cannot be conducted at that location, or if any of the conditions below are not met,do
not sign this approval.
I CERTIFY TEAT THE GOV-RNING BODY OF THE KI CITY f OF I I HAS:
i J COUNTY
A) APPROVED THE APPLICANT AS BEING SUITABLE TO`ESTABLISH, MAINTAIN OR OPERATE A MOTOR VBHICLE DISNIANTLwG
2U StNESS(ORIGI NAL APPLICATIOEdS ONLY).
i 6) DETERMINED THAT THE LOCATION OR PROPDS=-D LOCATION Nt=ETS TH= REQUIREM IENTS FOR THAT LOCATION UNDER ORS
i e'n.tt0.
Q DETERMINED THAT T'.-IE LOCATION DOES NOT tRflLTT=1rM1NY A?P+IOA-L=PROVISION OF ORS e22135.
I Df APPROVED THE LOCATION AND DETEgWNED THAT T'.-IE LOCATION COI.IPLI=S WITH ANY REGULATIONS ADOPTED BY TiiE
JURFSDICTIOPI UNDER QRS 522140.
Date Received: i
♦ PLACESTAMP ORSEAL MERE v i
NOV 17 2011 I�
ILII APPROVED
Original Subrriittal CITY OF SPRINGFIELD
1
I ALSO CERTIFY THAT I AM AUTHORIZED TO SIGN THIS APPLICATION p
AND AS EVIDENCE OF SUCH AUTHORITY DO AFFIX HEREON THE .1
1 SEAL OR STAMP OF THE CITY OR COUNTY. }
91L -z— I „1I IQtr i 1 E II111 I ( I��GNiN@ERJoAV- SOI
}SIGMA .E I (OATE 1 1 1
io'x
ply
_ WR2030
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 Corporation or LLC,then Oregon registered agent name and address required below.
pREGON REGISTERED AGENT RAMS (� "eELEFHONE NU6IEER
11 ( CLr1C'P LP 1-(���J( (v-5A i )14-1-3Y--P4
12 JOREGON REGISTERED.AGEW SMEEI ADDRESS I CITY (STATE f ZIP CODE
13 OFEGGN REGISTERED.AGEN I MAILING ADDRESS JIF DIFFE RENT) CITY STATE ZIP'-ODE
13A National Motor Vehicle Title Information System (NNIVTIS)number REOUIRED: oC)
(Ii OWNERSHIP INFORMATION
�R{kIC17-h1M�1=P> n'N' sr�ART-01GR, ,-. .,.:.,.....e=1en€ReRA-'-t-�]FFlGSR LAE -REaID.r.tJ'e .�eou^w'IEUJ?:rBE:
14 HARRAL, CHARLES W T PRESIDENT ( ) (541) 744-2468
15 DATE OF FIRTH I DRIVERLIGEP%E NUMEER I f STATE OF ISSU ^2CF
RESIDENCE ADDRESS 'CnY STATEZIP CODE
16 40145 DEERHORN RD SPRINGFIELD 97478
17j"iAIu"C ADDRESS(IF DIFFEF.ENPI I tCITY STATE ZIP CODE
18 EPUFf ING SIGNATURE OF OWNER SHv114 ON UNF 14 AEO4r if DATE
'PRINT NAME OF OV4FIERIPARTNERt LLCMEMBER!CORPORATE OFFICER TI'iYE RESIDENCE TEI-PHONE NUMEER
191 HARRAL, KENNETH C I I SEC ( ) (541) 206-4434
DATE OF FIRTH I DRIVER LICENSE NUMHR STATS OF ISSNC
UAE
20
RESIDEFIC=Ay7DRES5 QTY STATE ZIP CODE
21 1371 W31TH ST I � SPRINGFIELD f 97478
IMAADDRESS(IF DIFFEREN-1) I I CITY STATE[Z4 CODE
22
tI
ERi IFi 1NG sIG1uTURE OF OWNER aiaM ON LICE 19.ABOVE DATE
23
PRINTJIAA1=ilF.U'»m,e^.er.gTn� �.p,Enmra t-elco rR — - e I Tlle .p.E$IDENL TLEP40' !'!1}.LS-
24� 1
( )
25 DATE OF E -.iRTH I DRIVER LICENSE NU :P=_R I t STATE OF R5UANICE i
26�F.ESIDEh! A -DRESS I �CiTY STATEjZIPCODE
27 IMAILING AODRES9(IF DIFFERENT) t CITY STATE 4 I ZSG CODE
C-EET
FY It SIGNATURE Cr 0ViNER SHOWN*ON LIN'E 21 A°OLE E DATE
28X
29 Please attach (staple) copies of ALL owners, partners, LLC members or corporate officers official photo ID's
(driver license or state Issued Identification card ONLY ). If the residence address on the photo ID Is different
than the residence address listed on Page 2, submit a statement explaining why the addresses do not match.
Copy must be legible.
False certification is a Class 6 misdemeanor under ORS 162.085 and is punisha RftZMdii, a fine of up to
S1,000 or both. In addition, DMV sanctions against you or your dismantbar certificate may be Imposa•d. With this in mind... I
certify that I am the owner, a partner, an LLC member,for a corporate officer of thisa and that all information on
this application is accurate and true. I certify that the right of way of any highway ad�t h20flation listed above is
used for access to the premises and public parking.
Pag1?2 Original Submittal
W R2030
ADDITIONAL INFORMATION
CHANGING YOUR BUSINESS NAME—You need to file) a correction application (Form 735-3738) with DMV 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 rider from your bonding company;
• Contact Business Registry at 503-986-2200 to change your business name; and
• A fee of$30.
CHANGING YOUR BUSINESS LOCATION — If you move your yard, you need to file a correction application (Form
735-3738) with DMV before you conduct dismantler business. 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 rider from your bonding company;
• A plat map or description of the location of the premises; and
• A fee of$30.
CHANGING YOUR BUSINESS NAME AND LOCATION —You need to file a correction application (Form 735-373B) with
DMV 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:
• A rider from your bonding company;
• Location approval from the city or county;
• A plat map or description of the location of the premises;
• Contact Business Registry at 503-986-2200 to change your business name; and
• A fee of$30.
OTHER CHANGES— You need to file a correction application (Form 735-373B) 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 rider from your bonding company;
• Photo ID; and
• A fee of$30.
SUPPLEMENTAL LICENSE — You need supplemental business certificate for each additional location where you
conduct dismantler business. The supplemental location I 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) needs to 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); and
• A fee of$90.
DUPLICATE LICENSE — It you need a duplicate dismantler certificate issued, you need to contact our office and pay a
fee of $30.
Date Received:
If you have any questions,.please contact the Businesls License Unit at 503-945-5052. NOV 17 2011
Pag9 I ° Original Submittal
1
0 0
SURETY BOND I • BOND NUMBER
NOTE: TO BE COMPLETED BY1BONDING COMPANY. FAILURE 801317
TO ACCURATELY COMPLETE THIS FORM WILL CAUSE
DELAY. PLEASE TYPE OR PRINT LEGIBLY WITH INK.
LET IT BE KNOWN:
THAT SPRINGFIELD AUTO RECYCLERS,INC
(OWNER,PARTNERS,LLC OR CORPORATION NAME)
DOING BUSINESS AS
(ASSUMED BUSINESS NAME,IF ANY)
HAVING PRINCIPAL PLACE OF BUSINESS AT 750 S 28TH STt SPRINGFIELD,OR 97477
(ADDRESS,CIN,STATE,ZIP CODE)
WITH ADDITIONAL PLACES OF BUSINESS AT
(ADDRESS,CITY,STATE,ZIP CODE)
(ADDRESS,CITY,STATE,ZIP CODE)
STATE OF OREGON,AS PRINCIPAL(S),AND CONTRACTORS BONDING AND INSURANCE COMPANY
(SURETY NAME)
1201 NE Lloyd Blvd.,SUITE 360 PORTLAND, OR 97232 ( 503 )287-6000
(ADDRESS,CITY,STATE,ZIP CODE) TELEPHONE NUMBER
A CORPORATION ORGANIZED AND EXISTING UNDER AND BY VIRTUE OF THE LAWS OF THE STATE OF Washington ,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$10,000 FOR THE PAYMENT OF WHICH THEA 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 PRINCIPAL(S) IS ISSUED A DISMANTLER CERTIFICATE TO
CONDUCT A MOTOR VEHICLE DISMANTLING BUSINESS IN THIS STATE, SAID PRINCIPAL(S) 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 VEHICLES DIVISION OF THE OREGON
DEPARTMENT OF TRANSPORTATION. THIS BOND SHALL EXPIRE UPON EXPIRATION OF THE DISMANTLER CERTIFICATE, BUT MAY 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 JANUARY 1,2012 AND EXPIRES DECEMBER 31,2014 /BOND MUST EXPIRE ON THE\
(MONTH,DAY,YEAR) (MONTH.DAY,YEAR) ` LAST DAY OF THE MONTH.
--ANY ALTERATION VOIDS THIS BOND--
IN WITNESS WHEREOF,THE SAID PRINCIPAL 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 15TH DAY OF SEPTEMBER 2011
(MONTH) (YEAR)
SIGNAT OF OWNER,PA LF1 ORCORPO EOFFICER TITLE
X
SIGNATURE OF SURETY RIZED REPRESENTATIVE) I TITLE
X ATTORNEY IN FACT
SURETY'S AGENT OR REPRESE ATIVE MUST COMPLETE THIS SECTION: PLACE SURETY SEALBELOW
IN THE EVENT A PROBLEM ARISES CONCERNING THIS BOND,CONTACT: R,+,
,
NAMETELEPHONE NUMBER
CONTRACTORS BONDING AND INSURANCE COMPANY 503 287 6000 D to Received`; t }
ADDRESS
PO BOX 12053 NOV 17 Mil '•`-'- '=' -
,
CRY,STATE,ZIP CODE (.,,,"��,,,.I^!\,"
PORTLAND, OR 97212-0053 'I .
APPROVED BY ATTORNEY GENERAL'S OFFICE OriginalUt)R11ttal 1 -
Page 3
Contractors cgand Insurance Company POWER OF ATTORNEY
tzts Valley Stret
cy street
P.O.Box WA 9 A9 g p Contractors Bonding and Insurance Company
...0�� Seattle. 8109-0271 Y
Bund No. 801317
Know All Men by These Presents:
That the Contractors Bonding.and Insurance Company--t a corporation organized and existing under the laws of the State of
Washington ,mid authorized and licensed to dol business in all states and the District of Columbia does hereby make,
constitute and appoint: KAREN ALGER in the City of PORTLAND State of
OREGON , as Attorney in Fact , with full power and authority hereby conferred upon him/her to sign.
execute, acknowledge and deliver for and on its behalf as Surety, in general,any and all bonds, undertakings, and iecognizances in an"
amount not to exceed Ten Million and 00/100 Dollars ( $10.000.000.00 1 for any single
obligation,and specifically for the following described bond. -
Principal: SPRINGFIELD AUTO RECYCLERS INC
Obligee: STATE OF OREGON/MOTOR VEHICLE DIVISION _ .. .
Type Bond: AUTO WRECKERS.
Bond Amount: _ .$10,000.00__
Effective Date: _01/01/2012.--.-...-._-'----..—.__-----------._—_-- — —.--._--—
The Contractors Bonding and Insurance Company further certifies that the following is a true and exact copy of a
Resolution adopted by the Board or Directors of CoatractorslBondine and Insurance Comn:mv ,and now in force to-wit:
i "All bonds, policies, undertakings, Powers of Attorney or other obligations of the Corporation shall be executed in the ;
corporate name of the Corporation by the President,Secretarv,any Assistant Secretary,Treasurer,or any Vice President,or j
by such other officers as the Board of Directors may authorize. The President,any Vice President,Secretary,any Assistant ;
Secretary, or the Treasurer may appoint Attorneys in Fact or Agents who shall,have authority to issue bonds, policies or
undertakings in the name of the Corporation. The corporate seal is not necessary for the validity of any bonds, policies,
undertakings, Powers of Attorney or other obligations of the Corporation. The signature of any such officer and the
corporate seal may be printed by facsimile or other electronic image."
IN WITNESS WHEREOF,the Contractors Bonding and Insurance Co nary has caused these presents to be executed by,
its Vice President with its corporate seal affixed[his 15 day of SEPTEMBER 2011
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ATTEST: gcP•••'P e•-•9'*r1 Contractors Bonding and lnsuranee,Company
Ar
'Pop, F
u
• , 0 =a? SEAL ,'.= —
''s'•.
Jean 1 Stephenson VSecretary • . .•' °- Roy C.DVice President
Stott Oran upn,�J•110
.
On this 15 day of SEPTEMBER .2011 before me,a Notary Public.persona , cared Roy C.Die
and Jean M.Stephenson .who being by me duly'sworn,acknowledged that they signed the above Power of Attorney
as Vice President and I Secretary ,respectively,of the said
Contractors Bonding and Insurance Company. , and'acknowledged said instrument to be the voluntary act and deed of
said corporation. - I`
�I1 ,1tinne
nDate Received:
�.r.r tilnlenf MsaM1inRlnn
JOSEPH B.MULLER Q.
Joseph B uller Notary Public MYCOMMISS1ON EXPIRES NOV I I LO��
I Mxch2s.2at2 / 7
Original Submittal
A0006311
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HARRAL,CHARIES WLLIAM
750 S 28TH ST
I '• pO BOX 127 �• 'i';
!; SPRMGFlELD;OR 87477
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Date Received:
NOV 17 2011
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Date Received:
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