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Home My WebLink AboutAdden 1CAG-18-287, Adden #1-19 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION DATE APPROVED a' - VALID UNTIL. 3 - %a -Iq CAPTAINt;__ �4j1 \� rr iii ASHING N STATE PATROL Q� EQUIP T & STANDARDS REVIEW UNIT RAL ADMINISTRATION BLDG �`. BOX 42600 For Department Use Onry) OL0 YMPIA WA 98504.2600 This application must ho submitted by the Chief Executive of the firm or corporation making application Please type or print in ink. Person, Company, Department, or Agency (it a person, must list agencyidepartment representing) Premier Motor Escort, LLC Address PO Box 55634 City Shoreline State WA Zip 99153.0634 Phone 22q $42-4763 E-mail PremierMotorEscort@comcast.net t Purpose of ApphcatlonlAuthority Describe below the specific purpose for which the vehicles) wilt be used as authorized emergency vehicle(s) and what necessitates permitting as an aulhohzed emergency vehicle The purpose should include the nature and scope of the duties, responsibilities, and intended uses of emergency equipment, as welt as the statutes that give authority for the listed equipment and uses. We provide molor escort services to local Funeral Directors rind Families in a time honored tradition devoted to those 111111 have passed in a procession of their loved ones to the place of internment while keeping the safety of the procession and general public at the forefront, RCW 46.37 194 Chapter204-36 WAC WAC 309-3304" WAC 204-36-OA3) +nwm+r Mwnh Page t 0r 5 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION tw. 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 YEAR LICENSE NO 2006 41)9116 MAKE MODEL Ilonda ST1300EX i• VIN Jt12SC51706M400268 REGISTERED OWNER i DeBanolu. Thomas P I VEHICLE INFORMATION YEAR LICENSE NO 2017 9209LEM MAKE MODEL H-D FLHTP 2• VIN I I I D I FMC 13H R643262 REGISTERED OWNER Pamiczk , Julius VEHICLE INFORMATION YEAR LICENSE NO 3017 7E8101 MAKE MODEL II-1) FLHTP 3. VIN I I I I)1 FMC 1 X1IB655974 REGISTERED OWNER I � Hybridge, John VEHICLE INFORMATION YEAR LICENSE NO 2000 2D8902 MAKE MODEL KawasakE KZ1000 4. VIN J KAKZ.CP24Y 8518386 REGISTERED OWNER Nislu uri. Kenneth W EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODE ® SIREN Whelen — - _ PA 112 ® LAMP(S) (location/cotors) Front Red/Clear Whelen + LINZ6 ides. Red/Clear Whelen - — _ + LINlh ® OTHER EQUIPMENT _Rear Red/Clear Whelen AIR3.+_])4RRRR Clear Strobe 3M Qpticorn R92H EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL SIREN Whelen 'W PA 112 ® LAMP(S) (locationitolom) Front- RedfClear Whelen 00 Sides. Red/Clear Whelen Sao a LIN3 ® OTHER EQUIPMENT Rear. Red'('lear Whelen 500 Clear Strube Nova CPE EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL SIREN. Whelen - - -- 1)210R LAMPS) (locationloDlors) -- Front. Red1clem Whelen INZ6 Array Sides Red/Clear Whelen 00 + L1N3 OTHER EQUIPMENT — Rear RC&Clear Whelen. EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL ® SIREN Fenn_ix — torm Pro ® LAMP($) (loeation/eolom) - Front. Red/C}ear Whelen Sides Red/Clear Whelen OTHER EQUIPMENT F Rear. Red/Clem Whelen _ 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 Page 2 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT 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 commefcial insurance in Washington State or business use exemption must be provided pursuant to WAC 204-36-040 I VEHICLE INFORMATION I 2017 9016LEM MAKE MODEL 11-n FLHTP 5. VIN 1111)I FMC 13HB643830 REGISTERED OWNER L � Radford, Earl Slantey Jr VEHICLE INFORMATION YEAR LICENSE NO 2005 6C4291 MAKE MODEL BMW R1150RT 6• VIN W B I0499A85ZF'96222 REGISTERED OWNER 9U VEHICLE INFORMATION YEAR LICENSE NO 006 1F4256 MAKE MODEL Ronda ST1300 7• VIN � J H2 S(' 51716M,100294 REGISTERED OWNER David 6 VEHICLE INFORMATION YEAR LICENSE NO 1999 TOM-17 MAKE MODEL Kawasaki K71000-P18 8., VIN J KAKZCPP25 X A517259 REGISTERED OWNER DeBartolo, Thomas P EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL SIREN Whelen __.. WSSPA 0 LAMP(S) {ioeationlmlore) Front: Red/Clear Whelen_ PNZ6 Arne Sides Red/Ctear Whelen t-IN76 ❑ OTHER EQUIPMENT Rear Red/Clear Whelen LIN7.6 EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL SIREN - Code 3 050 - ® LAMP(S) (tocationlcolats) Front: Red/Clear Code SELEDFI2 Sides Red/Amber Cade 3 SELEDF 12 El OTHER EQUIPMENT Rear: Red/Clear Code .. .- PSELEDF12 EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL ® SIREN Whelen SA314 ® LAMP(S) (locationlc fors) Front. Red/Clew Whelen IANZ6 Array Sides Red/Ciew Whelen TIR6 �y OTHER EQUIPMENT (tear Red/Cle,ar Whelen 1TIR3 + 14_RRRR EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL ® SIREN Whelen JWPA 112 ® LAMP(S) (locationlcolors) Front Red/Clear Whelen +_TIR6 Sides Red/Clear Whelen "TIR6 + 500 ❑ OTHER EQUIPMENT Rear Red Whelen 5110 • I)-1RRRR 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. a000aaa OW ORersa) Page 2a of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT ;.�1, 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 operatorldriver 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 (if applicable — see WAC 204-36-040) New? Thomas P DeBartolo DEBARTP395BS 395615 - Expires- 02/2021 Twyla R DeBartolo DEBARTR389BJ 377616 - Expires: 01/2020 Anthony J DeBartolo DEBARAJ0970E 389487 - Expires: 09/2020 Julius E Parniczky PARNIJ*363Q6 407595- Expires. 04/2021 John Hybridge HYBRIJ*528JG 360390 - Expires- 05/2019 Kenneth W Nishiyori NISHIKW377JA 334246 - Expires- 03/2020 Ear) Stanley Radford Jr RADFOES465RT 374214 - Expires. 05/2019 Serge FE Royer ROYERSF419DP 346608 - Expires. 04/20220 David Scott Kringle KRINODS397RH 389969 - Expires- 08/2020 3WO-323.006 (R ens) Page 3 of 5 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 ® City streets (list all cities) Algona, Arlington, Auburn, Bainbridge Island, Bellevue, Black Diamond, Bonney Lake, Bothell, Bremerton, Brier, Buckley, Burien, Carnation, Cie Elum, Covington, Des Moines, DuPont, Duvall, Edgewood, Edmonds, Ellensburg, Enumclaw, Everett, Federal Way, Fife, Gig Harbor, Granite Falls, Issaquah, Kenmore, Kent, Kirkland, Lacey, Lake Forest Park, Lake Stevens, Lakewood, Lynnwood, Maple Valley, Marysville, Medina, Mercer Island, Mill Creek, Milton, Monroe, Mountlake Terrace, Mukilteo, Newcastle, Normandy Park, Olympia, Orting, Pacific, Port of Seattle, Poulsbo, Puyallup, Redmond, Renton, Roy, Sammamish, Seatac, Seattle, Shoreline, Snohomish, Snoqualmle/North Bend, Sumner, Tacoma, Tukwila, University Place, Woodinville. FM iliWrI M173 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: 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) 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 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 vehicte(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 Isabrlity as well as cancellation of this permit as outlined under chapter 204-36 WAG. 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, Premier Motor Escort, LLC {CHIEF Eft4WIVE OFFICER) Name Tom DeBartolo Date 02/23/2018 (TYPE OR PRINT) amo-Wa-rM(Rm+s) Page 4 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION or fi. 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 SIGN or fire department, it must be CERTIFIED by the head of the political sub -division The certification must H E R E 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 l Signature Date 5/uII thtle 4- 6l6vLf- Name Ey.-IJV�►]t-� Jurisdiction �� {Pieria P'm Phone 2S) 4 7.y — -7 f b'7 E-Mail Restrictions " eW4 C- Signature Name SPlease Prr111 Phone ( Restrictions Signature Name Phone c Restrictions Signature Name Phone Restrictions Date Title Jurisdiction E-Mail Date Title Jurisdiction E-Mail Date Title Jurisdiction E-Mail Signature Date Name Jurisdiction fp"" Pam, Phone t } E-Mall _ Restrictions Signature Date Name Jurisdiction (P[Qe P„I) Phone ( ) E-Ma€I Restrictions 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 3000313t309 fR N753 Page 5 of 5 Insurance Company[ies]: Mesa Underwriters Specialty Insurance Co Date of Mailing: June 4, 2018 Policy Number: MP0046003007852 Kind of Policy: COMMERCIAL GENERAL LIABILITY Issued Through: Griffin Underwriting Services Submission #: 17086122 Name of Elite Motor Escort Inc DBA Olympic Motor Patrol Insured: PO Box 66897 Burien, WA 98166 Agent of Bordelon Insurance (New Business) Insured: 3801 150th Ave SE #300 Bellevue, WA 98006 Phone. 425-455-2227 Property Location (if other than mailing): 240 SW 139th St, Burien, WA 98166 Griffin Underwriting Services Authorized Representative: Effective 12/27/2018 at 12:01 a.m. at the location of the property involved, we hereby non - renew the above policy in accordance with the terms and conditions of the policy. The reason for the non -renewal is: Non-compliance with audit. CERTIFICATE OF MAILING I hereby certify that I personally mailed with the U S Postal Service on June 4, 2018 a Notice of Cancellation to the above Insured, as exact copy of which appears above, and at said time received from the U S Postal Service the receipt made part hereof or attached hereto (7) Signed by Mary Feld X y The City of Renton 1055 S Grady Way Renton, WA 98057 City of Renton Chief of Police 1055 S Grady Way Renton, WA 98057 RENTON POLICE DEPARTMENT JUN 06 2018