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Home My WebLink AboutContractAUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION WASHINGTON STATE PATROL EQUIPMENT & STANDARDS REVIEW UNIT GENERAL ADMINISTRATION BLDG PO BOX 42600 OLYMPIA WA 98504-2600 DATE APPROVED: ____ _ VALID UNTIL: _____ _ CAPTAIN: _______ _ For De ar tment Use Onl This application must be submitted by the Chief Executive of the firm or corporation making application. Please type or print in ink. Person, Company, Department, or Agency (if a person, must list agency/department representing) PREMIER MOTOR ESCORT, LLC Address PO BOX 55634 City SHORELINE State WA Zip 98177-0634 Phone (206) 542-4763 --- E-mail premie rmotorescort@comcast.net 1.Purpose of Application/Authority: Describe below the specific purpose for which the vehicle(s) will be used as authorized emergency vehicle(s) and what necessitates permitting as an authorized emergency vehicle. The purpose should include the nature and scope of the duties, responsibilities, and intended uses of emergency equipment, as well as the statutes that give authority for the listed equipment and uses. Premier Motor Escort provides motor escort services to local Funeral Directors and Families in a time honored tradition devoted to those that have passed in c! procession of their loved ones to the place of internment while keeping the safety of the procession and public at the forefront. Authority: RCW 46.37 .194 WAC Chapter 204-36 WAC 308-330-466 WAC 204-36-050(3) 3000·323--006 (R 8/15) Page 1 of 6 CAG-25-350 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION [ill)■ I il .. t,r 2.Ve�icle lnfo�mation: _List all vehicles intended to be used as authorized emergency vehicles. For eachv�h1cle, prov1d� _a!I vehicle and �mergency �quipr:ient in !ormation as outlined below. Prior approval must begiven before ut11iz1ng a new vehicle or a vehicle with equipment installed other than what is authorized underthe current permit for that vehicle. Proof of insurance for each vehicle must be attached pursuant to WAC204-36-030. If providing funeral escorts, proof of commercial insurance in Washington State or businessuse exemption must be provided pursuant to WAC 204-36-040. VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2012 7G8660 � SIREN WHELEN iwPA112 MAKE MODEL HONDA ST1300P � LAMP(S) (location/colors) FRONT -RED/CLEAR WHELEN �OO+LINZ6 1. VIN SIDES -RED/CLEAR WHELEN lsoo+UNZ6 JH2SC513XCK000014 REAR -RED WHELEN 500+LINZ6+ TIR3 REGISTERED OWNER 0 OTHER EQUIPMENT: REAR LGHTBAR WHELEN ID4RRRR /red\ THOMAS P DEBARTOLO VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2009 5F4039 � SIREN WHELEN iwPA112 MAKE MODEL HONDA ST1300P � LAMP(S) (location/colors) FRONT -RED/CLEAR WHELEN �OO+LINZ6 2. VIN SIDES -RED/CLEAR WHELEN lsoo+UNZ6 JH2SC51769K600684 REAR -RED WHELEN 500+LINZ6+ TIR3 REGISTERED OWNER � OTHER EQUIPMENT: REAR LGHTBAR WHELEN b4RRRR lredl THOMAS P DEBARTOLO CLEAR STROBE 3M OPTICOM /792H VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2006 0L7759 � SIREN WHELEN M'PA112 MAKE MODEL HONDA ST1300P � LAMP(S) (location/colors) �OO+LINZ6 FRONT -RED/CLEAR WHELEN 3. VIN SIDES -RED/CLEAR WHELEN 1500+LINZ6 JH2SC51716M400294 REAR -RED WHELEN 500+LINZ6+ TIR3 REGISTERED OWNER 0 OTHER EQUIPMENT: REAR LGHTBAR WHELEN b4RRRR Ired\ DAVID LEFFEBVRE I VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 0 SIREN MAKE MODEL 0 LAMP(S) (location/colors) 4.VIN REGISTERED OWNER 0 OTHER EQUIPMENT: I Note: This page may be copied if additional vehicles need to be added to the permit. Any additional sheets attached must provide the vehicle and equipment information in the same format as above. 3000-323--006 (R 8/15) Page 2 of6 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION 2.Vehicle Information: List all vehicles intended to be used as authorized emergency vehicles. For eachvehicle, provide all vehicle and emergency equipment information as outlined below. Prior approval must be given before utilizing a new vehicle or a vehicle with equipment installed other than what is authorized underthe current permit for that vehicle. Proof of insurance for each vehicle must be attached pursuant to WAC204-36-030. If providing funeral escorts, proof of commercial insurance in Washington State or businessuse exemption must be provided pursuant to WAC 204-36-040. VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2009 9J6590 [2l SIREN WHELEN WPA112 MAKE MODEL HONDA ST1300 [2] LAMP(S) (location/colors) �X TIR3, 1X ION FRONT -RED/WHT WHELEN 5. VIN STOBE -CLEAR NOVA tPE JH2SC51749K600621 SIDE -RED/WHT WHELEN 2X 500 SERIES/LINZ6 REGISTERED OWNER [2l OTHER EQUIPMENT: REAR LIGHTBAR -RED WHELEN !DOMINATOR 4RARATIMOTHY HAUN TRUNK LEDS -RED/WHT WHELEN/ABRAMS 12x TIR3/2X E-D300 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2017 7E8101 [2l SIREN WHELEN 6D210R MAKE MODEL HD FLHTP [2] LAMP(S) (location/colors) luNz6 ARRAY FRONT -RED/CLEAR WHELEN 6. VIN SIDES -RED/CLEAR WHELEN 15oo+LIN3 1HD1FMC1XHB655974 REAR -RED WHELEN 500 REGISTERED OWNER [2l OTHER EQUIPMENT: CLEAR STROBE NOVA lcPE JOHN HYBRIDGE VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2013 1J1285 [2l SIREN WHELEN WPA112 MAKE MODEL CANAM SPYDER [2] LAMP(S) (location/colors) !ENFORCER/FLEXFRONT -RED/CLEAR WHELEN 7. VIN SIDES -RED/CLEAR WHELEN !ENFORCER 2BXNCBC14DV002916 REAR -RED WHELEN ENFORCER REGISTERED OWNER 0 OTHER EQUIPMENT: VERN EARL JOHNSON JR VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 0 SIREN MAKE MODEL D LAMP(S) (location/colors) I 8. VIN I REGISTERED OWNER 0 OTHER EQUIPMENT: I Note: This page may be copied if additional vehicles need to be added to the permit. Any additional sheets attached must provide the vehicle and equipment information in the same format as above. 3000-323-006 (R 8/15) Page 3 of 6 AUTH ORIZED EMERGENCY VEHICLE PERMIT APPLICATION 3.Operators: Please list all drivers that will be authorized to operate the vehicle(s) listed in this application and indicate whether or not the operator/driver is new since your last application by placing an X in the "New?" column; otherwise, leave this column blank. No drivers should be listed unless they have been appro ved. Per WAC 204-36-040, all operators involved in traffic control must be a Washington State certified flagger, and carry their certified flagger card at all times. Name Driver's License Number Flagger Certification Number New? (if applicable -see WAC 204-36-040) THOMAS P. DEBARTOLO WDL45TPG243B AT3014912 -Expires: 04/2027 ANTHONYJ DEBARTOLO WDL426N8253B AT3004904 -Expires: 09/2026 JOHN HYBRIDGE WDL6361F283B AT3023567 -Expires 07 /2028 VERNON JOHNSON WDL2R8R8483B AT3017170 -Expires: 07 /2028 JULIUS PARNICZKY P65242O64426O (FL) AT3013830-Expires: 06/2027 TWYLA R DEBARTOLO* WDL1B8NGD13B AT3004910 -Expires: 09/2026 TIMOTHY HAUN WDL5TRT5O93B 10780480 -Expires 08/2028 DAVID LEFFEBVRE WDL69NT3683B AT3021732 -Expires 05/2028 y PROVIDES TRAFFIC CONTROL SERVICES ONLY. 3000-323--006 (R 8/15) Page 4 of6 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION 4.Geographic Area: Indicate which types of roads and which specific geographic area(s) the authorized emergency vehicles will be used. Certification from each jurisdiction is required under WAC 204-36-030. Certification is covered in section 6 of this application. [8J City Streets (list all cities) City of RENTON -�----------------------- D County Roads (list all counties) D State Routes/Interstates (list all state routes, interstates, and counties) 5.Permit Validation: I certify (or declare) under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct to the best of my knowledge, information, and belief, and that: a.All of the information given in this application is correct to the best of my knowledge and provided in its full format to the undersigned chief law enforcement officer or fire chief (if the vehicle is to be used for firefighting purposes) of each primary jurisdiction in which the vehicles are to be used as authorized emergency vehicle(s). b.None of the drivers, to the best of my knowledge, in the last year, have been convicted of, nor served any sentences or periods of probation for any felonies, nor arrested and convicted of a drug or alcohol violation or illegal use or possession of drugs, nor been required to register as a sex offender. c.Only the vehicle(s) and equipment listed in this application will be used as outlined in this application, and that only the operators listed under this permit will drive the vehicle(s). As the primary holder or executive officer in charge of overseeing this permit, I understand that if the permit is issued, it is my responsibility to ensure: a.No driver listed in this permit uses the vehicle for any purpose not authorized under this permit unless all emergency equipment is removed or covered. b.No driver other than those listed under this approved permit operates the vehicle(s) listed unless all emergency equipment is removed or covered. If I wish to add a new driver or vehicle to this permit, I must receive prior approval before they are authorized under this permit. c.The driver must exercise due care and caution and must obey all traffic laws. I understand that the inappropriate or misuse of authorized emergency vehicles may result in criminal or civil liability as well as cancellation of this permit as outlined under chapter 204-36 WAC. In addition, I understand that it is my responsibility to ensure that a copy of this permit listing all approved drivers and geographic areas authorized, as well as a copy of the vehicle permit authorizing emergency equipment is present in each vehicle at all times and must be presented to law enforcement, if requested. Signat ure Tom DeBartalo (CHIEF EXECUTIVE OFFICER) Name Tom DeBartolo (TYPE OR PRINT) 3000-323-006 (R 8/15) Title Owner, Premier Motor Escort, LLC Date 11/01/2025 Page 5 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION 6.Certification: This application for an Authorized Emergency Vehicle Permit will not be accepted unless CERTIFIED by the chief law enforcement officer or fire chief (if the vehicle is to be used for firefighting purposes) of each primary jurisdiction in which the vehicle(s) are to be used as authorized emergency vehicles (see part 4 of this application). If the application is made by the chief of a law enforcement agency or fire department, it must be CERTIFIED by the head of the political sub-division. The certification must include the following language: "I hereby certify that I have reviewed this entire application; that I am aware that the applicant intends to use the vehicle(s) and emergency equipment listed in part 2 of this application, for the specific purposes listed in part 1 of this application; that a need exists in my jurisdiction for the listed vehicle(s) to be used as authorized emergency vehicles and that the applicant has the appropriate authority as described in part 1 of this application to operate such equipment; and I know of no reason why this application should be denied." Please type or pri � c � Signature � (�e�s?1!t) joYl �'v, V \ d-\ Phone ('-(25) L/3o-JS-6S Restrictions Date \ -z .q.zo'Title �h .e-.f__,,,::::....,:c...:.,_c..=_....:...._ _____ _ Jurisdiction Kevi� E-Mail JScHU t-D1@(2e.,yi-k>vi WA ,901.../ --------------------------------- Signature Name (Please Print) -------------- --"---'------------Phone Restrictions ---Date Jurisdiction E -Mai I Title --------------------------------- Signature Name ------------- (Please Print) -------------- -->---'------------Phone Restrictions Signature Name ------------- (Please Print) --------------Phone Restrictions Date Title ---- Jurisdiction E -Mai I Date Title ---- Jurisdiction E -Mai I --------------------------------- Signature Name (Please Print) --------------Phone Restrictions Signature Name (Please Print) -------------- --"---'------------Phone Restrictions ----Date Jurisdiction E -Mai I ----Date Jurisdiction E -Mai 1 Title Title Note: This page may be copied if additional certifications need to be added to the permit. Any additional sheets attached must provide the certification information in the same format as above. 3000-323--006 (R 8/15) Page 6 of6