Loading...
HomeMy WebLinkAboutContractAUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION 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 Motor Escort Address PO Box 66897 City Burien State WA Zip 98166 dave@elitemotorescort.com Phone (206)466-2161 E-mail Ieroybarker@msn.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. Assist local Funeral Directors and their"families"in a time honored tradition devoted to those that have Passed in procession of their loved ones to a place of internment while keeping the safety of the procession And general public at the forefront. RCW 46.37.194 Chapter 204-36 WAC WAC 308-330-446 WAC 204-36-050(3) 3000-323-006(R 8/15) Page lip CAG-18-287 AUTHORIZED EMERGENCY VEHICLE PERMIT 51 MGIOM Slllf P 1NOl 1 APPLICATION mr 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 AL-1 Lein q 1`l Lt SIREN X li-%he-k k f' tkg A 112-- MAKE MOD L LAMP(S)(location/colors) cur l ey - I- HI P Rex.), 00D-or c- I a Ey flc\5 c.DN) 1. VIN A}_t t t?ar 1 OD 1 FThillitiiThLkcl-1 a REGISTERED OWNER OTHER EQUIPMENT: DA-VE Ea A y VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 206-3. L-e.i•v1 7400 g SIREN u-1 k N Lt4 el+ I 1 2- MAKE MODEL Et LAMP(S)(location/colors) Fort? Crow(Ni 1(re:.tori a. Mei Frair SvO D o c4 EPIi05Di3D 2. VIN re(l rear tolvei.e.Iv Pa r 3(Z, ar—A FP7 I WI ) ( I),7.X0In REGISTERED OWNER OTHER EQUIPMENT: ear VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 900 Q 0 lie-V 1 7 a gl'SIREN 5hbnv - 3(1,.X1 09 MAKE MODEL LAMP(S)(location/colors) Hark) 11 TPA i-Rd/i.;. h,1--2--ralr cccLe 3 SPIT i-tU 3. VIN red Lett . 1-rcb .5144 Ir-3(v FL!o/E 2 WO FTh(r114 81(45134 r-t o Fre N t to k e .e-fv/ SP 5 6 4:v REGISTERED OWNER OTHER EQUIPMENT: PCttf IG k FtoGb VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR -- LICENSE NO. INSTALLED MAKE n MODEL Dour 6 08E8 c1 - RSIREN whew -iv SA.3tyMAKEMODEL .. LAMP(S)(location/colors) Iio 0 ck 6 c_5 it- Reel LJ M I.0 fle-leti 2(ri P 4. VIN q Red FR N r iehe:l e :ir Alc14..J t 51Ito 1r1ct002 4 Real -5iCid u:h-t rf Ti A (o REGISTERED OWNER OTHER EQUIPMENT:L)he.t eta i-vY-re5 . j v1 U- F-eti' iv, — N„1 +-c ' DFL-tRaR 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 oil AUTHORIZED EMERGENCY VEHICLE PERMIT s®G,o.s®® APPLICATION E ' ' 4)ff 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 200(o q KO G V 1 1 SIREN LIJhZ1 C IN( WP Ft , MIMAKE MODEL LAMP(S)(location/colors) 14artt_y FL 1-1 IPL pee Fro t Cade_ 3 Par L4 g , VIN I l'IDI HktI%oY4B7O ( e el Kea h R..1e, Ir (o REGISTERED OWNER MOTHER EQUIPMENT: et VI NI Cent- r5 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSENO. INSTALLED MAK MODEL 2_008 L-L- v 11 I `4`3 t8 SIREN wil‘t.le.h (4,(5 3a0 MAKE MODEL LAMP(S)(location/colors) Asir lei rziee- T' C 11 k- :pi t c-'' Red Fro N +- u!hw.k .i yoo trr/ cofrr V VIN i 1-IDI r11M 1 X8Y(0&. . 4 6 Ktd tRt.x.tr 5h0--m - iI • 800ct - REGISTERED OWNER OTHER EQUIPMENT: PAN/ I Q C em e-Nf. S1-zi L( 5OledSid I am P Try k-[; he-.sib fi VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED //MAKE A, MODEL 2OO I 007750 21 SIREN Ai 1b 1 San 1 L'(c.. e0t4'Ch5 l'C.AMAKEMODELLAMP(S)(location/colors) J Kuwa etki KZ J6 u P ec1 fow-i- -- w he Teti Par3 S VIN JK A K ZC 23185 1914/ R-ed d'-c. S+rol: Trtic Lit REGISTERED OWNER EdOTHER EQUIP ENT: 1{en r.Si(h e-L T z- (jcl,IKanne.t-1. Co c 1 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2w i 0434 Lem SIREN 6)alr.kty' i4-1 e Fi MAKE MODEL LAMP(S)(location/colors) IV Rarky' FL-WTI'I L\ f uNt V,11`tr alr36, C s VIN tc1 k) [tc, ar u;he-k..N 1,ix) rres 10 I rn m r G E 16 7%, RtI// h t e, oot St i,U Kiel— REGISTERED OWNER OTHER EQUIPMENT: Tlrttf I (4 a.)Lz 1 r r a rri r Opti corn 3 in 5-V ro b 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 AUTHORIZED EMERGENCY VEHICLE PERMIT l ,®,,® „® APPLICATION iL 1 li ;l 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 aid MODEL J 34 SIREN h CN 35 L l4 MAKE MODEL LAMP(S) (location/colors) CI VINI-ar le)/f 1 N r I c1 ftO 4' - rect r u;hel N' 10(pau,,,) REGISTERED OWNER OTHER EQUIPMENT: f f)C fhtiu Lai 3 c VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSEt,NO. INSTALLED MAKE MODEL J3 LE In I OUP SIREN he C,IV 13ft35 0 P1 14 MAKE MODEL LAMPS)(location/colors) r riz r t-I4T FRQrJt Rest fuiiii-e. rectr 6ide P L N -c.,I 0 0 VIN 1HDI FP)17) 18 F661624 73 REGISTERED OWNER OTHER EQUIPMENT: Lqr RaCA-COrdr VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE yy c NO. INSTALLED MAKE MODEL V0'C: `1 k 3 1 t SIREN 0 MAKE MODEL , LAMP(S) (location/colors) I-Vctr ley F L It TT - Hair_gi-P _?_ - v)h, lei- 0116,11+DIIlkVIN 1110iF (11rr1130y7°C) ,B REGISTERED OWNER OTHER EQUIPMENT: fcxjer 3`rtC.rw Oc'c1 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR L- LICENSE NO. INSTALLED MAKE MODEL O 1-- 61^ RA91 IREN i.)kiE.I`/ (OPftIII MAKE MODEL RSLAMP(S) (location/colors) , I'VON C_ Sri 3coPA red ( rv i r WI1'tt N' yoFF5C10D0-5 l .1.• VIN r ti 'u FroP fi !Wen" zcti t T3 Sli25C.5I 7y q KC u0(,:r'zd jhi(-e_1ek Whe_IeN Ti R3 REGISTERED OWNER OTHER EQUIPMENT: Ti/Y1 c+by (-1- a uri Rik-&itY le_ .r% -FL F13 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 ea q AUTHORIZED EMERGENCY VEHICLE PERMIT I!??s . APPLICATION ru- 1 !, 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 2_00 7 L4j j5L4 SIREN A1ek r Si.1 350'PI rl MAKE MODEL LAMP(S)(location/colors) I+c r'e v 1-L I ri) i Lea Root I e 4 pa r3('.:S'n.D-Led re RVINbe =ea r s i ci - d/h-}z I r r"JJ o te" T( ly 4,1i 3 REGISTERED OWNER OTHER.EQUIPMENT: l AN/ Leh sick-(carted/whr i-r .lc 8 7- i R. OGMRA Led raid i vbo -I eat h t wlid i 7OACk Fe- R VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO._ '' INSTALLED MAKE MODEL OI C 3 80 2) a SIREN I eihp gAIOR_ MAKE MODEL LAMP(S)(location/colors) , Parley FLI-4-f en 7d0S -fr - o VIN 1 - L f — 1 14 0 I F 0 a60 8A 7 o rer d w11 e..1 eN Po,r 3 REGISTERED OWNER OTHER EQUIPMENT: Keiv'iV'.ti L Coble r Gtl'' 501= reci W h e 700 5erle 5 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 22p20_L — J i LE SIREN MANE EL 13 I W I t °RI— LAMP(S)(location/colors) 15- 0 VIN wi3 JO4 [ if (idl"7Oo83 REGISTERED OWNER OTHER EQUIPMENT: Wick) la5 all VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR - 7 LICENSE NO. 1 INSTALLED AKi E MODELS 1ooaASCo570GsSIRENWI053111 MAKE MODEL l LAMP(S)(location/colors 1I (o 0 1u nSa .1 r©N r- Red r c <<e IC UO hrrlG . -C-,rtrs501 VN Sf gQot CV , t_ „Teb--3_+±4 Strobz S- J >< t+ pzLW .5r. 5q3 c_K Rz P REGISTERED OWNER Co 1-1/Y1-6111/ 6 U W OTHER EQUIPMENT: bi L, ,E# 4f 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 8115) Page Ma _S--- AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION l I 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 F 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[ L LICENSEE N/O. Q INSTALLED MAKE MODEL gOO_ O F l (S I 5 SIREN MAKE MODEL LAMP(S)(location/colors) i f- cri r -I 7 1-3 I Fp] aikq We070,t7 REGISTERED OWNER OTHER EQUIPMENT: Forre_e- y-i- W U/`a ff VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL SIREN MAKE MODEL LAMP(S) (location/colors) 2. VIN REGISTERED OWNER OTHER EQUIPMENT: VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL SIREN MAKE MODEL LAMP(S)(location/colors) 3- VIN REGISTERED OWNER OTHER EQUIPMENT: VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL SIREN MAKE MODEL LAMP(S)(location/colors) 4. VIN REGISTERED OWNER OTHER EQUIPMENT: 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 imp /. AUTHORIZED EMERGENCY VEHICLE PERMIT 51 OYGTOM Sf.IE V TNOL APPLICATION ti U, [ 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 nagger Certification Number New?if applicable—see WAC 204-36-040) I . C ,/fer3 f1e,iviN J ,C.tIVTE ( J1 G Nib 2 , (]erent DAV I d Epley k ( l eme c f318O3 C.x-3 5-2oZ, NO 3. (,00t2 't.twe-#I Lee.. C.OoLek.L53Diq 13).53i p,3-5-ZOzc, ki0 Lt. Curricrivr 1ceu aewi" CorrL.a143"15N(k 0 ,ns-2Oza N O 57 Each y, Th4vr' Erick 40e5VD5 33' t3 I,(P. 3-s-wu) NJO 6. -o , tt('<< y i 1)liam r x i J37(3 P 339a3 Z -z01e U 7' 14 viG. Forre HuIcth-fDy°l0'A 33-thi exp o- - ZO c, NI () a Ink;i rstricum.-. chae.( :xl,;,,3jn--'t3.rN 33yz3 en to 03 --Zo Le N 0 9. LAiLcol( -kthe - P • Lai somcLu LO1 37b07' E, , 7-9 -LOIS NO lO Meyer1?auIa , Ileyerpacis1 r\_ 33`I 42 cx?. 3 s-Zazo KID II. Rc -rd Cardcrn Ij-IF, 'a a fo e 5`i°r r 374aH EXp 5-a3 _-iq 0 I., 5hert ooci, Roe r ' . Sher t•'ra50occ 33a4i Exp., 3--5-2oz0 No 13 l c fJ1 T r nath H aon 4rTt<.`11 q K.D 35 8358 EXP z 7-2.6 ter N 0 N. C.oa h ref ANdlretki,S, Cosh rqs )89 KF3 334 ,tif5 E-_>`p.3--SI/620 yes 5 ehti,, NI cho 14 5 EA Li I`Ai' Y 3 3 q 244 r=/i zoza yes 3000-323-006(R 8l15) Page % 7 AUTHORIZED EMERGENCY VEHICLE PERMIT wasuwcrou STATE PATROL APPLICATION f 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) e iNt-to County Roads (list all counties) 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. Signature f _,ice Title Perm 1 r reel-or "Olrd/ve-t CHIE EXECUTI FICER)--' Name L.r: Ve as Date (9 I - 18 TYPE OR PRINT) 3000-323-006(R BN5) Page 4 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT ELM 5W 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 print: Signature v6--)2/1/4"- N1 Date C(/z'5(/I '6 Title A c.„-r\N Name Please Print) 0 \is A-1-J M Jurisdiction Phone (yzs) L3o- 1 Sb-7 E-Mail Eue,v„uc,ven c 6-av Restrictions oe..1 Signature Date Title Name Please Print) Jurisdiction Phone ( )E-Mail Restrictions Signature Date Title Name JurisdictionPleasePrint) Phone ( )E-Mail Restrictions Signature Date Title Name Please Print) Jurisdiction Phone ( )E-Mail Restrictions Signature Date Title Name JurisdictionPleasePrint) 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 5 of 5 7.01151014, 1 qQ • 1 If, S .(...1 Obi 1 • . fsMO, Contact information Elite Motor Escort CEO Dave Eady daveeady@msn.com 206)466-2161 BOD Member Doug Clark drelark3@hughes.net 360) 275-5614 Permit Administrator Leroy Barker leroybarker@msn.com 206) 940-0523 ELITE MOTOR ESCORT INC. 206) 466-2161 Your Safety Is Our Concern" AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION DATE APPROVED: VALID UNTIL: CAPTAIN: WASHINGTON STATE PATROL EQUIPMENT & STANDARDS REVIEW UNIT GENERAL ADMINISTRATION BLDG PO BOX 42600 For De artment Use Onl 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) Regional Motorcade, L.L.L.P. Address 3211 West McGraw St. Ste#99022 City Seattle State WA Zip98139 Phone (888)988-1723 E-mail cowboy@regionalmotorcade.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. The ONLY purpose,and intended use,of these vehicles are for FUNERAL ESCORTS using lights and sirens to alert the public of our approach,presence and intent to escort the funeral procession to the place of internment by the route which is both legal and practicable in accordance with WAC 308-330- 466; and having equipment which has met the requirements of RCW 46.37.190 (Warning devices on vehicles) facilitates requesting other vehicles to yield the right-of-way and immediately drive to a position parallel to, and as close as possible to.the right-hand edge or curb of the roadway clear of any intersection and stop and remain in such position until the authorized emergency vehicle has passed in accordance with RCW 46.61.210. The purpose of this application is for the safety of pedestrians,other vehicles,the procession participants and the escort vehicle operators. The nature of the duties and responsibilities of each operator extend only to the safety of the procession in compliance with local laws and jurisdictional restrictions and does not relieve the operator of an authorized emergency vehicle from the duty to drive with due regard for the safety of all persons using the roadways. 3000-323-006(R 8/15) Page 1 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION imr 3000-323-006(R 8/15) Page 2 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT 4 TROL APPLICATION 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 2013 LEM9718 SIREN Whelen ISA-350-MH MAKE MODEL LAMP(S) (location/colors) H/D FLHTP Pursuit Lights Whelen PAR-36 Clear-Red 1. VIN Front Forks S-Link System Clear-Red 1 HD1 FMM 15DB651436 REGISTERED OWNER MOTHER EQUIPMENT: Windshield Array Whelen MO4Z* Clear-Red Albert Mitchell Radio Box Whelen Ser 500 Red VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2014 7C6153 SIREN Whelen WAP112/SA350 MAKE MODEL LAMP(S) (location/colors) H/D FLHTP Pursuit Lights Whelen PAR-36 Clear-Red 2. VIN Radio Box Whelen Dual LED Clear-Red 1 HD 1 FMM 13EB616413 REGISTERED OWNER OTHER EQUIPMENT: Patric Kelly VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2013 LEM9525 SIREN Whelen jPA 100 MAKE MODEL LAMP(S) (location/colors) H/D — FLHTP Pursuit Lights Whelen PAR-36/200Clear-Red 3. VIN Bags& Fender Whelen LINZ6/TIR3CIear-Red 1 HD 1 FMM 14DB645837 REGISTERED OWNER MOTHER EQUIPMENT: Radio Box Whelen TIRE/500 Clear-Red Douglas Morgan Windshield Array Whelen M01LD Clear-Red VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2011 LEM9792 SIREN Whelen jW320 H rMAKE MODEL LAMP(S)(location/colors) H/D FLHTP Pursuit Lights Whelen Par 36 Clear-Red 4. VIN Bags& Fender Whelen LIN 26 Clear-Red 1 HD1 FMM 14BB638710 REGISTERED OWNER MOTHER EQUIPMENT: Box _ Whelen 7ORCSFCR Clear-Red David Stering Windshield Array Whelen MOILD Clear-Red 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 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 XSIREN Code 3 1200 RT-P 2013 9344LEM XLAMP(S) (location/colors) MAKE MODEL Pursuit Lights Torus TSX3-R 5 BMW R1200 Telescoping Pole Redtronic EM303 VIN Side Light Code 3 TSX3-R WB1044003DZW22005 OTHER EQUIPMENT: REGISTERED OWNER Side & Rear Code 3 TRX6-R PAUL FISON VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL XSIREN WhelenC/R ' WPA112 2014 LEM9696 XLAMP(S) (location/colors) MAKE MODEL Pursuit Lights WhelenC/R PAR 36 6 H/D FLHTP Rear Box Whelenc/R 400 Dual LED VIN Rear Box WhelenC/R TIR6 1HD1FMM1XE619695 X OTHER EQUIPMENT: REGISTERED OWNER Windshield Array WhelenC/R MO1LD Thomas Chiswell Crashbar Whelen Red LIN6 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL XSIREN CODE 3 R1200RT-P 2009 9371LEM XLAMP(S) (location/colors) MAKE MODEL Pursuit Lights TORUS TSX3-R 7. BMW R1200 Side+Rear Code 3 TSX3-R VIN Side+Rear Code 3 Optix 3/4 WB103880029ZT15446 X OTHER EQUIPMENT: REGISTERED OWNER Rear WhelenTIR-6 Red LED Thomas Chiswell Telescoping Pole Redtronic EM403 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL XSIREN FED SIGNAL MS 100 2003 0E9906 XLAMP(S) (location/colors) MAKE MODEL Pursuit Lights Redtronic BX62 8. BMW R1150CHP Telescoping Pole Redtronic EM304 VIN Side Lights Redtronic BX3 I WB10499A63ZE89539 X OTHER EQUIPMENT: REGISTERED OWNER Side& Rear Code 3 LED-R Regional Motorcade LLLP 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. AUTHORIZED EMERGENCY VEHICLE PERMIT IO,.® APPLICATION tux' 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 204-36440) Albert Mitchell MITCHA*539CH 312561 No Thomas Chiswell CHISWTJ456NM 312562 No Douglas E Morgan MORGADE397QP 312563 No Paul Fison FISONPW429NA 363988 No Patric Kelly KELLYPB471 MB 312565 No Dave Stering STERIDL412BD 312567 No David Wyatt WYATTDW361BR 375347 No 3000-323-006(R 8/15) Page 4 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT yawn ..4ttM 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 City Streets (list all cities) / ,fro.../ County Roads (list all counties) 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. Signature '_-4, Title President C IEF EXECUTIVE OFFICER) Name Albe itchell Date February 15, 2018 TYPE OR PRINT) 3000-323-006(R 6n5) Page 5 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT Al[ 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 print: Signature ot( Date Title eferpXpe- Name ,/ Please Print) K VI(`- Jurisdiction Phone (qi.) 1430 -731:'S E-Mail Yet)Iof r.aftl 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 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