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Home My WebLink AboutCAG2020-275 - Original - Premier Motor Escort, LLC - Authorized Emergency Vehicle Permit Application - 08/25/2020ApprovalOriginator:Department: Date Sent:Date Required: Authorized to Sign: o Director or Designee o Mayor Date of Council Approval: Budget Account Number: Budget? o Yes o No Grant? o Yes o No Type:Review/Signatures/RoutingDate Received by City Attorney:Comments: Date Routed to the Mayor’s Office: Date Routed to the City Clerk’s Office:Agreement InformationVendor Name:Category: Vendor Number:Sub-Category: Project Name: Project Details: Agreement Amount: Start Date: Basis for Selection of Contractor: Termination Date: Local Business? o Yes o No* *If meets requirements per KCC 3.70.100, please complete “Vendor Purchase-Local Exceptions” form on Cityspace. Notice required prior to disclosure? o Yes o No Contract Number: Agreement Routing Form For Approvals, Signatures and Records Management This form combines & replaces the Request for Mayor’s Signature and Contract Cover Sheet forms. (Print on pink or cherry colored paper) Visit Documents.KentWA.gov to obtain copies of all agreementsadccW22373_1_20 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION Etm-W 2 Vehicle lnformation: 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. lf 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 1 YEAR 2009 LICENSE NO 5F4039 MAKE Honda MODEL STI3OOP VIN JFDSC51769K600684 REGISTERED OWNER DeBartolo, Thomas P VEHICLE INFORMATION 2. YEAR 1999 LICENSE NO 4F4096 MAKE Kawasaki MODEL KZIOOOP VIN JKAKZCPP2'XB'17259 REGISTERED OWNER DeBartolo, Thomas P VEHICLE INFORMATION 3. YEAR 2006 LICENSE NO 0G1243 MAKE Honda MODEL STI3OOP VIN JH2SC5 171 6M400294 REGISTERED OWNER DeBartolo, Thomas P VEHICLE INFORMATION 4. YEAR 2006 LICENSE NO 4D9tt6 MAKE Honda MODEL STI3OOP VIN JH2SC5 1706M400268 REGISTERED OWNER DeBartolo, Thomas P 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. / ,l E n EMERG ENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL X srneru lwp,qt tzWhelen O + LINZ6 O + LINZ6 LAMP(S) (locationicolors) Sides: Red/Clear Whelen Front: Red/Clear Whelen 3M + Clear Strobe Rear: Red OTHER EQUIPMENT: EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL X slner,l \rVhelen lwper rz + 500 + TIR6 LAMP(S) (locationicolors) Sides: Red/Clear Whelen Front: Red/Clear Whelen OTHER EQUIPMENT: + EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL X slner.l lsa:r+Whelen O + LINZ6 O + LINZ6 LAMP(S) (location/colors) Sides: Red/Clear Whelen Front: Red/Clear Whelen OTHER EQUIPMENT: Clear Strobe Nova + EMERGENCY EQU¡PMENT INFORMATION INSTALLED MAKE MODEL lwpet tzX srne¡t Whelen + LINZ6 + LINZ6 LAMP(S) (location/colors) Whelen Front: Red/Clear Whelen Sides: Red/Clear OTHER EQUIPMENT: Clear Strobe + 3M 3000-323-006 (R 8/15)Page 2 of 5 AUTHORIZED EMERGENCY VEHIGLE PERMIT APPLICATION H"A*"qm ruromtr 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. lf 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 5 YEAR 2017 LICENSE NO 92O8LEM MAKE MODEL FLHTPH.D VIN IHDlFMCl3Tß643262 REGISTERED OWNER Parniczky, Julius VEHICLE INFORMATION 8. YEAR 2017 LICENSE NO 90I6LEM MAKE H-D MODEL FLHTP VIN IHDIFMC13HB64383O REGISTERED OWNER Radford. Earl Stanley Jr 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. D I d EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL lwparrzX srneru Whelen OO + LIN3 00 LAMP(S) (location/colors) Sides: Red/Clear Whelen Front: Red/Clear Whelen Nova 00 Clear Strobe OTHER EQUIPMENT: EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL X stneru lsozronWhelen + LIN3 LAMP(S) (locationicolors) Sides: Red/Clear Whelen Front: Red/Clear Whelen OTHER EQUIPMENT: VEHICLE INFORMATION YEAR 2017 LICENSE NO 7E8l0l MAKE H-D MODEL FLHTP VIN lHDlFMClXÍT8655974 6. REGISTERED OWNER Hvbridse. John VEHICLE INFORMATION 7 YEAR 2000 LICENSE NO 2D8902 MAKE Kawasaki MODEL KZlOOOP VIN JKAKZCP24YBsI8386 REGISTERED OWNER Nishiyori, Kenneth'W, EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL X srneru Fennix lstorm Pro LAMP(S) (locationicolors) Sides: Red/Clear Whelen Front: Red/Clear Whelen OTHER EQUIPMENT: EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL [wsspe¡oX srne¡t Whelen LAMP(S) (location/colors) Sides:Red/Clear Whelen Front: Red/Clear Whelen OTHER EQUIPMENT 3000-323-006 (R 8/15)Page 2a of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION H"p"Æm uffirytr 2 Vehicle lnformation: 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 ihe current permit fır that vehicle. Proof of insurance for each vehicle must be attached pursuant to WAC 204-36-030. lf 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 t0 YEAR LICENSE NO MAKE MODEL VIN REGISTERED OWNER VEI.IICLE INFORMAT¡ON 11 YEAR LICENSE NO MAKE MODEL VIN REGISTERED OWNER VEH¡CLE INFORMATION 12 YEAR LICENSE NO. MAKE MODEL VIN REGISTERED OWNER 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. EMERGENGY EQUIPMENT INFORMATION INSTALLED MAKE MODEL lwpar lzX stnr¡t Whelen Ælex LAMP(S) (location/colors) Front: Red/Clear Sides:Red/Clear OTHER EQUIPMENT Rear: Amber VEH¡CLE ¡NFORMATION YEAR 2013 LICENSE NO 881792 MAKE CanAm MODEL Spyder VIN 2BXNCBCI4DVOO29l6 9 REGISTERED OWNER Johnson, Vernon Earl Jr EMERGENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL [l slne¡t LAMP(S) (locationicolors) OTHER EQUIPMENT: EMERGENCY EQU¡PMENT INFORMATION INSTALLED MAKE MODEL n srne¡t LAMP(S) (location/colors) OTHER EQUIPMENT: EMERG ENCY EQUIPMENT INFORMATION INSTALLED MAKE MODEL n slnr¡¡ LAMP(S) (location/colors) OTHER EQUIPMENT: 3000-323-006 (R 8/15)Page 2b of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION 0mñ- üfliflsfr" 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. 'l J J "l 2úq*&- 2Ð15 ftl.L ?)tbWcçl ( v lÉtt¿W¿dzorlkccøqs\r4 ú Driver's License Number Flagger Gertification Number (if applicable - see WAC 204-36-040)New?Name DEBARTP395B8 395615 - Expires: 0212021Thomas P Detsartolo WDLIBSNGDl3B 437772 - Expires: 0812023Twyla R DeBartolo* 389487 - Expires: 0912020Anthony J DeBartolo DEBARAJO9TOE WDLsBRPJD23B 408603 - Expires: 0812021Catharine M Devine* PARNIJ*363Q6 407595 - Expires: 0412021Julius Parniczky RADFOES465RT 429575 - Expires: 0512022Earl S Radford 431335 - Expires: 0212023Kenny Nishiyori NISHIKW3TTJA HYBRIJ*528JG 426603 - Expires: 0612022John Hybridge 4D005768P (Idaho)346608 - Expires: 0412020**Serge Royer 389969 - Expires: 0812020KRTNGDS39TRHDavid S Kringle WDL2R8R8483B 412081 - Expires: 01 12022Vernon Johnson DEBARAJO9TOE 432082 - Expires: 0812022Christina R DeBartolo* 415664 - Expires: 0212023WDL3I S9OG63BCraig Herkenhoff * * Wuiting for Flagger Classes to reopen.*Only provides Traffic Control Services. 3000-323-006 (R 8/15)Page 3 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION H"m,Æffi ru[Þ{t7 4. Geographic Area: lndicate 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)Citv of Kent County Roads (list all counties) State Routes/lnterstates (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. lf 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. ln 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 Tòm Ða&wtolo Title Owner Premier Motor Escort LLC (cHtEF EXECUTIVE OFFICER) Name Tom DeBartolo 3000-323-006 (R 8/15) (TYPE OR PRINT) Date 311712020 Page 4 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION H"mffit[#ffi 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). lf 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: "l 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: Signatu Name (PIease Print) Phone (Ðss) ttÍt- - re Date Q.8. *¿ Title d¿! nl //,* Jurisdiction ð/ k*l E-Mail 3 Restrictions Signature Date Jurisdiction E-Mail Title Name (Please Print) Phone ( ) Restrictions Signature Date Jurisdiction E-Mail Title Name (Pleâse Print) Phone ( ) Restrictions Signature Date Jurisdiction E-Mail Title Name (Please Print) Phone ( ) Restrictions Signature Name Date Jurisdiction E-Mail Title Phone ( ) (Please Print) Restrictions Signature Date Jurisdiction E-Mail Title Name (Please Pr¡nt) Phone ( ) 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 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION H"m#ffiuffiffi WASHINGTON STATE PATROL EQUIPMENT & STANDARDS REVIEW UNIT GENERAL ADMINISTRATION BLDG PO BOX 42600 oLYMP|A WA 98504-2600 DATE APPROVED: VALID UNTIL: CAPTAIN: (For Department Use Onlv) 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, orAgency (if a person, must list agency/department representing) Premier Motor Escorl, LLC. Address PO Box 55634 City Shoreline State WA Zip 98155-0634 Phone (206) 542-4763 E-mail PremierMotorEscort@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 a procession of their loved ones to the place of internment while keeping the safety ofthe procession and general public at the forefront. P(CW 46.37.194 WAC Chapter 204-36 wAC 308-330-466 wAC 204-36-0s0(3) 3000-323-006 (R 8/15)Page 1 of 5