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Home My WebLink AboutCAG2018-0352 - Supplement - Premier Motor Escort, LLC - Authorized Emergency Vehicle Permit Application - 03/22/2019 AUTHORIZED EMERGENCY VEHICLE PERMIT ®1'614""MW-HIMO?ON 61ATE PAiAOL APPLICATIONI�f DATE APPROVED: VALID UNTIL: _ CAPTAIN: WASHINGTON STATE PATROL EQUIPMENT & STANDARDS REVIEW UNIT GENERAL ADMINISTRATION BLDG PO BOX 42600 (For Department Use Only)1. 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) Premier Motor Escort, LLC. Address PO Box 55634 City Shoreline State WA Zip 98155-0634 Phone (206)542-4763 E-mail PreniierMotorEscort c,comcast.net 1. Purpose of ApplicationlAuthority: 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 a procession of their loved ones to the place of internment while keeping the safety of the procession and general public at the forefront. RC W 46.37,194 Chapter 204-36 WAC WAC 308-330-466 WAC. 204-36-050(3) 3000-323-006(R 8115) Page 1 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT ?J5�1r. M, APPLICATION =1V 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 2006 41)91 I6 ® SIREN _ Whelen Wl'A112 MAKE MODEL ® LAMP(S)(location/colors) I londa ST 1300EX Front: Red/Clear_ Whelen 400+LINZ6 1 VIN Sides: Red/Clear Whelen k00 i LINZ6 1112SC51706M400268 _ REGISTERED OWNER Z OTHER EQUIPMENT: Rear: 1tcd+'C'iiar Whelen 1113 i p4RRRR DeBartolo,'Thomas P Clear Strobe 3M Opticom 9211 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2017 9208LEM ® SIREN Whelen IWPAI 12 MAKE MODEL ® LAMP(S)(location/colors) 1-1-1) FLHTP Front: Red/Clear Whelen �..00- 00 2. VIN Sides: Red/Clear Whelen +LIN3 11 ID I FMC 131-113643262 REGISTERED OWNER ® OTHER EQUIPMENT: Rear Red/Clear Whelen �"PE 00 Parniczk , IL[IiLIS Clear Strobe Nova VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO- INSTALLED MAKE MODEL 2017 7E8101 ❑` SIREN Whelen 5D210R MAKE MODEL [] LAMP(S)(location/colors) H-D FLl ITP Front: Red/Clear Whelen iI.INZ6 Array 3• VIN Sides: Red/Clear Whelen 1500+LIN3 I H D I FMC I XH 13655974 REGISTERED OWNER ❑ OTHER EQUIPMENT: ILc'Lr: RcJ('leair Whelen i00 I lybridge,John VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2000 2D8902 ® SIREN Fennix storm Pro MAKE MODEL LAMP(S) (location/colors) Kawasaki KZ1000 Front: Red/Clear Whelen 4. VIN Sides: Red/Clear Whelen j JKAKZCP24YB518386 _ REGISTERED OWNER ® OTHER EQUIPMENT: Rear: Rod/Clear. Whelen Nishivori, Kenneth W- 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 2 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION i1 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 WAG 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 2017 9016LI3M ® SIREN Whelen JWSSPA30 MAKE MODEL ® LAMP(S)(location/colors) 11-1) FLIT1'13 Front: Red/Clear Whelen_ LINZ6 Array 5. VIN Sides: Red/Clear Whelen II..INZ6 I I IDI FMC13HB643830 REGISTERED OWNER ❑ OTHER EQUIPMENT: Rear: Red/Clear Whelen �INZ6 Radford, Earl Statilex Jr VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2005 6C4291 ® SIREN Code 3 3956 MAKE MODEL LAMP(S)(location/colors) BMW R 1150RT Front: Red/Clear Code 3 111SELEDIF12 6• VIN Sides: Red/Amber Code 3 iPSELEDF12 W F310499A 85Z E96222 REGISTERED OWNER ❑ OTHER EQUIPMENT: Rear: RcdVIe:u PSELED1:12 Royer,Sere F.F. _..._....._._ VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2006 1 F4256 ® SIREN Whelen i5A.314 MAKE MODEL LAMP(S)(location/colors) Honda ST1300 Front: Red/Clear Whelen LINZ6 Array 7• VIN Sides: Red/Clear Whelen IR6 .1112SC51716M400294 REGISTERED OWNER ® OTHER EQUIPMENT: Rear: Red/Clear Whelen FIR3 +D4RRRR Krin>jlc, David S. Clear Strobe Nova ,{:PE VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 1999 TOM-17 ® SIREN' Whelen IWPA112 MAKE MODEL ® LAMP(S)(location/colors) Kawasaki KZ 1000-1)18 Front: Red/Clear Whelen 200+TIR6 $. VIN Sides: Red/Clear Whelen rl R6+500 JKAKZCPP25XB517259 REGISTERED OWNER ❑ OTHER EQUIPMENT: Rear: Red Whelen E'•E500+D4RRRH DeBartolo,Thomas P 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 0/15) Page 2a of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT 9NINOTON i1lTE IMTPDI 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 yuAC 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 204-35-040) Thomas P DeBartolo DEBARTP395B8 395615 - Expires: 02/2021 Twyla R DeBartolo DEBARTR389BJ 377616- Expires: 01/2020 Anthony J DeBartolo DEBARAJ0970E 389487 - Expires: 09/2020 Catharine M Devine DEVINCM139JG 408603 -Expires 08/2021 Julius Parniczky PARNIJ*363Q6 407595 - Expires: 04/2021 Earl S Radford HYBRIJ*528JG 360390- Expires: 05/2019 Kenny Nishiyori NISHIKW377JA 334246 - Expires: 03/2020 John I lybridge RADFOES465RT 374214- Expires: 05/2019 Serge Royer ROYERSF419DP 346608 - Expires: 04/2020 David S Kringle KRINGDS397RH 389969 - Expires: 08/2020 Vernon Johnson 2R8R8483B 412081 - Expires: 01/2022 3000-323-006(R 8115) 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 20436-030. Certification is covered in section 6 of this application. ® City Streets (list all cities) ❑ County Roads (list all counties) U 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 timInd must be presented to law enforcement, if requested Signature ti,ti _ � _ Title Owner, Premier Motor Escort, LLC (CHIEF EXECUTIVE OFFICER) Name "Tom DeBartolo Date 03/01/2019 (TYPE OR PRINT) 3000-323-006(R 8115) Page 4 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT NnoN iaf<n� 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 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 t of this application to operate such equipment; and I know of no reason why this application should be denied." Please type or print: Signature Date d,3- -,D /V Title G-l�l��f a`,^Name 'tell (Please Print) r,a e, f Jurisdiction (, •� Phone (DZ) 261, - 9.8 DS- E-Mail Restrictions -- t Signature Date Title Name (Please Print) Jurisdiction Phone ( ) E-Mail Restrictions Signature Date Title Name Jurisdiction (Please Print) Phone ( E-Mail Restrictions Signature Date Title Name Jurisdiction (Please Print) 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 8115) Page 5 of 5