The URL can be used to link to this page

Home My WebLink AboutContractAUTHORIZED EMERGENCY VEHICLE PERMIT ELIONIM APPLICATION U R DATE APPROVED: VALID UNTIL: CAPTAIN: WASHINGTON STATE PATROL EQUIPMENT & STANDARDS REVIEW UNIT GENERAL ADMINISTRATION BLDG PO BOX 42600 For Department Use Only OLYMPIA WA 98504-2600 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) ELITE FUNERAL ESCORT Address 15609 CEDAR GROVE RD NE City POULSBO State WA Zip 98370 Phone (478)228-7544 E-mail bradleypss(cOutlook.com 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. Funeral Escorts with Traffic Control: In accordance with WAC 204-36-040(1)(e), vehicles used to conduct escorts must be registered emergency vehicles. Duties include: Traffic Control Responsibilities: Safety of funeral processions in accordance with WAC 204-36-030, 040, 050, 060, and 065. 3000-323-006(R 8/15) Page 1 of 6 CAG-21-050 AUTHORIZED EMERGENCY VEHICLE PERMIT i aw SN410N 5 •f PAi RCL APPLICATION 3000-323- 006(R 8/15) Page 2 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT ON® APPLICATION R 2. Vehicle Information: List all vehicles intended to be used as authorized emergency vehicles. For each vehicle, 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 under the current permit for that vehicle. Proof of insurance for each vehicle must be attached pursuant to WAC 204-36-030. If providing funeral escorts, proof of commercial insurance in Washington State or business use exemption must be provided pursuant to WAC 204-36-040. VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2015 BOY4738 SIREN CODE 3 MAKE MODEL LAMP(S)(location/colors) CHEVY TAHOE FR RED/WHITE UNDCVR VIZOR 1. VIN R RED/WHITE STL T R-6 1GNSK3EC4FR570800 REGISTERED OWNER OTHER EQUIPMENT: METROPOLITAN RAILROAD CORP. SIDE RED/WHITE STL T3 JACOB BRADLEY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2001 LEM7400 SIREN WHELEN MAKE MODEL LAMP(S)(location/colors) FORD CROWN VIC FRONT(RED/WH) WHELEN 2. VIN REAR(RED/WH)WHELEN 2FAFP71 W 12X 127206 REGISTERED OWNER OTHER EQUIPMENT: DAVID EADY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2006 9A0874 SIREN WHELEN MAKE MODEL LAMP(S)(location/colors) HARLEY FLHPI FRONT (RED/WH) 3. VIN REAR(RED/WH) 1 HD 1 FHW 116Y687015 REGISTERED OWNER OTHER EQUIPMENT: MELVIN J CENTERS VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2008 9143LEM SIREN WHELEN MAKE MODEL LAMP(S)(location/colors) HARLEY FLHTPI FRONT(RED/WH) 4• VIN REAR(RED/WH 1HD1FMM1X8Y685665 REGISTERED OWNER OTHER EQUIPMENT: DAVID CLEMENT 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 AUTHORIZED EMERGENCY VEHICLE PERMIT LE;`,; ,,:: 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 approved. 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) JACOB BRADLEY BRADLJDO87B5 SEE ATTACHED JAMES GREENE WDL3NNZ9J23B SEE ATTACHED WHITNEY NELSON WDL5S49B823B AS-WZF-O-20-00069 SCOTT GERBER GERBESM116R9 SEE ATTACHED MELVIN CENTERS CENTEMJ422RG 232532 ANDREW COCHRAN COCHRAS 189KB 334245 PATRICK HOCK HOCK*PW376JP 386021 MATTHEW STEINAUER STEINMR483NZ 334241 DAVID CLEMENT CLEMEDF378OS 232529 DAVID EADY EADY*DE590D5 334243 TIMOTHY HAUN HAUN*TL419KD 358338 ANDREW CURRIER CURRIAH375NA 232531 ETHAN SCOTHORN WDLBZ3B3853B AS-WZF-O-19-00360 3000-323-006(R 8/15) Page 4 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT i I0, $1Ifft PRIM APPLICATION UT' 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. City Streets (list all cities) Puyallup, Sumner, Lake Forest Park, Fife County Roads (list all counties) Skagit, Thurston State Routes/Interstates (list all state routes, interstates, and counties) WSP D8 (HWY 3, HWY 303, HWY 16,HWY 101, HWY 308,HWY 305) (KITSAP/ JEFFERSON/CLALLAM/ MASON/GRAYS HARBOR/PACIFIC/WAHKIAKUM) 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. Signature CHIEF Title OWNER CHIEF EXECUTIVE Name JACOB BRADLEY Date 04/10/2020 TYPE OR PRINT) 3000-323- 006(R 8/15) Page 5 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT TONS C APPLICATION u R 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. City Streets (list all cities) Renton, Fife, Auburn, Kent, Seattle, Puyallup Sumner, Milton, Mountlake Terrace, Lake Forest Park, Bothell, Federal Way, Des Moines, Bellevue County Roads (list all counties) King,Thurston, Skagit, Pierce, Snohomish, Whatcom, Mason State Routes/Interstates (list all state routes, interstates, and counties) 1-5, I-405, SR 167, SR 515, SR 16, SR 3(KING/PIERCE/KITSAP 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. Signature Title OWNER CHIEF EXECUTIVE OFFICER) Name JACOB BRADLEY Date 04/10/2020 TYPE OR PRINT) 3000.323-006(R 8/15) Page 5 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT P TOq„® APPLICATION R 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 emergency9Y 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 print: Signature l Date ?( V tle c\I\ 14- RA\cam, Name Please Print) eJurisdiction Ty ` Phone (i4 2A) ";D- 1 1 E-Mail N( 1r O -s Restrictions J Signature Date Title Name Please Print)Jurisdiction Phone (E-Mail Restrictions Signature Date Title Name Please Print)Jurisdiction Phone (E-Mail Restrictions Signature Date Title Name Please Print)Jurisdiction Phone (E-Mail Restrictions Signature Date Title Name Please Print)Jurisdiction Phone (E-Mail Restrictions Signature Date Title Name Please Print)Jurisdiction Phone (E-Mail Restrictions 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 of 6