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Home My WebLink AboutCAG2018-0336 - Supplement - Elite Motor Escort, Inc. - Authorized Emergency Vehicle Permit Application - 05/18/2020 Agreement Routing Form • For Approvals,Signatures and Records Management KENT This form combines&replaces the Request for Mayor's Signature and Contract Cover Sheet forms. WASHINGTON (Print on pink or cherry colored paper) Originator: Department: Jalene Police Date Sent: Date Required: > 12/17/2020 0 Authorized to Sign: Date of Council Approval: Q 0 Director or Designee ❑ Mayor Budget Account Number: Grant? ❑Yes ❑ No N/A Budget? ❑Yes ❑ No Type: Vendor Name: Category: Elite Motor Escort Application Vendor Number: Sub-Category: c N/A Extension Project Name: enc Emerg y Vehicle Permits E i Project Detailsfuneral Escorts with Traffic Control c a E Agreement Amount: Basis for Selection of Contractor: all Start Date: Termination Date: a1 Q Local Business? ❑Yes ❑ No* *If meets requirements per KCC 3.70.700,please complete"Vendor Purchase-Local Exceptions"form on Cityspace. Notice required prior to disclosure? Contract Number: ❑Yes ❑ No CAG2018-0336 Date Received by City Attorney: Comments: p1 C n 30 a, •� i � 3 � 40 f0 p� Date Routed to the Mayor's Office: V1 Date Routed to the City Clerk's Office: adccW22313_1_20 Visit Documents.KentWA.gov to obtain copies of all agreements r rA IM" AUTHORIZED EMERGENCY VEHICLE PERMIT I 1K ;„R�� APPLICATION =lr DATE APPROVED: 5/18/2020 VALID UNTIL: 5/18/2021 CAPTAIN: WASHINGTON STATE PATROL RENEWAL 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, INC Address 15609 CEDAR GROVE ROAD NE City POULSBO _ State WA Zip 98370 Phone (478)228-7544 E-mail BRADLEYPSS(a),OUTLOOK.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 Only: In accordance with WC 204-36-040(1)(e),vehicles used to conduct escorts must be registered emergency vehicles. Duties Include: Traffic Control for Funeral Escorts Only Responsibilities: Safety of funeral processions in accordance with WAC 204-36-030-065 �v�lehic4- �� 6 coyw4 d plaft see vel�ti c�el an new ,.9 0e1of8 3000-323-006(R 8/15) j AUTHORIZED EMERGENCY VEHICLE PERMIT A"IINGipr:fll:T :tR 60L APPLICATION luor 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 2002 LEM7400 ® SIREN WHELEN MAKE MODEL ® LAMP(S)(location/colors) FORD CROWN VICTORIA FRONT RED/WIIT) WHELEN 1• VIN REAR RED/WHT. WHELEN 2FAFP71 W 12X 127206 REGISTERED OWNER ❑OTHER EQUIPMENT: _ I DAVID EADY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2008 9225LEM SIREN SHOME 130.2104 _ MAKE MODEL ® LAMP(S)(location/colors) HARLEY FLHTPI RED/WHITE CODE 3 PTT40 2• VIN LED RED STROBE JE24 1 HD 1 FMM 148Y651348 REGISTERED OWNER ® OTHER EQUIPMENT: STROBE FLASH(RED) _ W HE1.FN SPS660 PATRICK HOCK STROBE LTS(RED) PAR36 OLIO VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2005 LEM9709 SIREN WHELEN ISA35OMH MAKE MODEL ® LAMP(S)(location/colors) HARLEY FLHP1 RED/WHITE WHELEN 03LR 3• VIN PURSUIT LTS(RED) AXITECH AR 36X10 1HD1FHW195Y668436 ENGINE GUARD(WHI-) WHELEN 500 REGISTERED OWNER ❑ OTHER EQUIPMENT: TOUR PAK RED WHELEN M4B4RSERIES MATTHEW STEINAUER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2009 OE8191 ® SIREN WHELEN MAKE MODEL ® LAMP(S)(location/colors) HONDA ST1300PA FRONT RED/WHT ABREM CLIPSE T3 4• VIN REAR(RED/WHT) WHELEN IR3 JH2SC51749K600621 SIDE(RED/WHT) WHELEN TIR3 REGISTERED OWNER ® OTHER EQUIPMENT: RED WHELEN OFFSCRC4005 TIMOTHY HAUN 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 6/15) Page 2 of 8 AUTHORIZED EMERGENCY VEHICLE PERMIT *-4 RK a.1141M.nr-'moos APPLICATION j= 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 2008 ' 434LEM 0 SIREN WHELEN JWPA MAKE N,,MODEL ® LAMP(S)(location/colors) HARLEY HT ''IV FRONT RED WHELEN AR 36 VIN hl REAR RED/WHT WHELEN ILIN3ARRAY 1HD1FM $76D7 FRONT SIDE R/W WHELEN TIR 4&1 HIDEAWAY 7ERED OW ( ® OTHER EQUIPMENT: STROBE 3M PTICOM CURRIER . VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YE LICENSE NO. INSTALLED MAKE MODEL 2002 4E7454 ® SIREN WHELEN SA-350-MH MAKE NMODEL ® LAMP(S)(location/colors) HARLEY FL: P1 FRONT RED/WHT PAR 36 MD-LED 2• VIN REAR&S1DE(REDjwtjTj UNDERCOVER 112TIR 1HD1FMW192 4215 REAR&SIDE RED/WHj' HALO 8TIR REGIST ❑ OWNE �1, Z OTHER EQUIPMENT: �11 . IZEARJSIDNREDIWI411 WHELEN ORCGFCR LAN W/ASHLEYCOCHRAN WINDSHIELD(REDIW M WHELEN LIM MISER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2006 9AO874 ® SIREN WHELEN IWPA-1 _ MAKE MODEL ® LAMP(S)(location/colors) HARLEY FLHP1 RED WHELEN IR-6 3• VIN 1 HD 1 FHW 116Y687015 REGISTERED OWNER ❑ OTHER EQUIPMENT: MELV1N J.CENTERS VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2008 9143LEM _® SIREN WHELEN WS-320 MAKE MODEL ❑ LAMP(S)(location/colors) HARLEY FLHTPI RED WHELEN 0R00XR11 4• VIN RED EHRLRN 0R00BRR 1HD1FMM1X8Y685665 REGISTERED OWNER ® OTHER EQUIPMENT: RED SHO•ME �050 I.8000SF DAVID CLEMENT RED TRUCK-LITE 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 8 AUTHORIZED EMERGENCY VEHICLE PERMIT I�� ,:� � APPLICATION or 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 2012 BIIX0384 SIREN CJB MAKE MODEL ® LAMP(S)(location/colors) DODGE CHARGER FRONT RAPTOR IR 1• VIN REAR XPRITE 2C3CDXAGOCH295580 REGISTERED OWNER ❑ OTHER EQUIPMENT: JACOB BRADLEY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2007 C06818P Z SIREN WHELEN 95HFSA6 MAKE MODEL ® LAMP(S)(location/colors) CHEVY IMPALA FRONT UNDERCOVER VZ LEALTH 4 2• VIN REAR RED RANGER KTAG TIR 2GIWSSSR679287538 REGISTERED OWNER Z OTHER EQUIPMENT: FRONTISIDE RED SOUND OFF L6-XP63 BRADLEY PUBLIC SAFETY&SECURITY AMBER UNGRADED IR-8 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2013 C06817P ® SIREN WHELEN MAKE MODEL ® LAMP(S)(location/colors) FORD TAURUS FRONT RED/WHT WHELEN 3• VIN REAR(RED/WHT) WHELEN 1 FAHP2M80DG 113556 REGISTERED OWNER ❑ OTHER EQUIPMENT: I BRADLEY PUBLIC SAFETY&SECURITY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2014 BNJ5508 ® SIREN CJB 120OW MAKE MODEL ® LAMP(S)(location/colors) FORD TAURUS RED/WHITE XPRITE L 4• VIN REAR BAR(WHT) XPRITE 8 1 FAHP2MT7EG 148262 REGISTERED OWNER ® OTHER EQUIPMENT: TRAFFIC ADVISOR XPRITE 00 JAMES GREENS LEDS REAR XPRITE 700 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 6/15) Page 4 of 8 AUTHORIZED EMERGENCY VEHICLE PERMIT AM -M st iler.W.MWl APPLICATION 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 12003 BOH2O65 SIREN CODE 3 135991,5 MAKE MODEL LAMP(S)(location/colors) DODGE DURANGO FRONT(RED/WHT) WHELEN IR 4 1. VIN SIDES RED/WHT LIBERTY -6 1D4HS48N33F596553 REAR REDIWHT) HAWTHORNE 160 W8HAW REGISTERED OWNER ® OTHER EQUIPMENT: REAR REDIW HT WHELEN JUNKNOWN JACOB BRADLEY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2015 BOY4738 SIREN CODE 3 13932 MAKE MODEL ® LAMP(S)(location/colors) CHEVY TAHOE WHT/RED UNDERCOVER Z500 2. VIN FRONT RED/WHT STL IR 3 IGNSK3EC4FR570800 FRONT REDIWHT STL TRAFF-3 REGISTERED OWNER ❑ OTHER EQUIPMENT: SIDES STL I R-3 JACOB BRADLEY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO- INSTALLED MAKE _ MODEL 2010 C19762T ® SIREN WHELEN ICJB20OW MAKE MODEL ® LAMP(S)(location/colors) CHEVY IMPALA RED/WHITE XPRITE 3. VIN 2GIWD5EM6A1233161 REGISTERED OWNER ® OTHER EQUIPMENT: TRAFFIC ADVISOR XPRITE. AMBER THOMAS HAUN FRONT GRILLE STL/TIR 3 [WHITE VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL SIREN MAKE MODEL ❑ LAMP(S)(location/colors) I 4. VIN _. .. REGISTERED OWNER ❑OTHER EQUIPMENT: 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 6/15) Page 5 of 8 AUTHORIZED EMERGENCY VEHICLE PERMIT 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 VVAC 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 BRADLJD087135 JAMES GREENE WDL3NNZ9J23B SCOTT GERBER GERBESMI 16R9 ANDREW CURRIER CURRIAH375NA 232531 MELVIN CENTERS CENTEMJ422RG 232532 ANDREW COCHRAN COCHRAS189KB 334245 PATRICK HOCK HOCK*PW376JP 386021 MATTHEW STEINAUER STEINMR483NZ 334241 DAVID CLEMENT CLEMEDF3780S 232529 DAVID EADY EADY*DE590D5 334243 TIMOTHY HAUN HAUN*TL419KD 358338 ETHAN SCOTHRON WDLBZ3B3853B 01900360 WHITNEY NELSON WDL5S49B823B ASWZF0200069 3000-323-006(R 8/15) Page 6 of 8 AUTHORIZED EMERGENCY VEHICLE PERMIT Al Ai J64 , APPLICATION .i 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) PUallu , 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 9aa&s Title OWNER IV (CHIEF EXECUTIVE O ICER) Name JACOB BRADLEY Date 04/10/2020 (TYPE OR PRINT) 3000-323-006(R 8/15) Page 5 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT ,! 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 p -� Signature = ` Date 4/13/20 Title Chief of Police y Name (Please Print) Michael Harden y Jurisdiction Lake Forest Park Police Dept_ Phone (206)957-2851 E-Mail m_ hardenncityofl .com Restrictions Follow RCW and rules of the road. Signature a e �v� r Title CG�� Name iii (Please Print) �-P�� t Jurisdiction lee k Phone &_ E-Mail Restrictions Signature Date Title Name Jurisdiction (Please Print) _ — _ —_- ._ Phone ( ) E-Mail Restrictions Signature Date _ Title _ Name Jurisdiction (Please Print) — _J� _ Phone _� _—� - - — _ E-Mail - - — Restrictions Signature Date 4 Title Name (Please Print) Jurisdiction Phone ) y E-Mail Restrictions Signature Date Title Name Jurisdiction (Please Print) _ _ _ — Phone - —� —- — — E-Mail - Restrictions Note: This page maybe 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 8H5) Page 6 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT :° "" APPLICATION i 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 Date %j_X i7p Title Gkidf W j&&20 Name �, � (PleesePrint) Jurisdiction � Phone E-Mail S Restrictions AW, 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 Signature Date Title Name (Please Print) _ _ Jurisdiction Phone l ) 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 6 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT ' "-1'1�"r APPLICATION wL*3fr 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: il Signature r I� L �J "_ Date 4/22/20� Title Chief of Police Name (Please Print) Brad Moericke Jurisdiction City of Sumner Phone (253)299-5641 E-Mail brad m(tI)sumnerwa.gc�v Restrictions Signature Date Title Name (Please PrInl) 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."(R 8/16) Page 6 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT ..R..= 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 taw 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 t 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 4-13-2o Title _Sheriff T Name iPleasePrint) Don McDermott Jurisdiction Skagit Couaty Phone (360)416-1911 E-Mail _donmc@ro.sk-agit.wa.us Restrictions Signature _ Date Title Name Jurisdiction (Please Prinl) _ Phone ( ) E-Mail Restrictions Signature Date Title Name (PleasePrint) Jurisdiction Phone ( ) E-Mail Restrictions Signature Date Title Name (Please Print) Jurisdiction Phone (� v — _ — — -- E-Mail — Restrictions Signature _ Y _ _ Date J Title Name (Please Print) Jurisdiction Phone ( �) E-Mail Restrictions Signature Date Title Name (Please Print) Jurisdiction ��Y 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 6115) Page 6 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT '?:�� ' APPLICATION �JW 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 I Date -X20Title (UXA5*A Name(Please Prinl) �o�.P. Jurisdiction Shtrn 'M Phone (30 24M.;60I E-Mail Tim , AA (y Cn.3BjAgM.(1,1A tI.s Restrictionsp 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 (Please Print) Jurisdiction Phone (_ ) _ _ E-Mail Restrictions Signature Date Title Name Jurisdiction (Please Print) -_ Phone C ) E-Mail Restrictions Signature Date Title Name Jurisdiction (Please Print) _ 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-M(R 8115) Page 6 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT U APPLICATION M. G. 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 _ Date 4/14/20 Title Chief of Police Name (Please Print) Peter Fisher Jurisdiction Fife Phone (253)896-8266 _ E-Mail _pfisher@,cityoffife.org Restrictions Signature Date Title Name Jurisdiction (Please Pont) — _-- Phone ( } E-Mail Restrictions Signature Date Title Name Jurisdiction (Phase Pnnl) _ _ _ —_. _ Phone ( )_ E-Mail Restrictions Signature Date _ Title Name Jurisdiction (Pieces Print) Phone { ) _ E-Mail Restrictions Signature Date Title Name Jurisdiction (Please Print) Phone ( )_ E-Mail Restrictions Signature Date _ Title Name Jurisdiction (Please Rini) _ — — Phone ( ) E-Mail Restrictions Note: This page maybe 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. 3OW323408{a SM5) Page 6 of 6 AUTHORIZED EMERGENCY VEHICLE PERMIT I 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 Date . 4/17/20 Title Captain Clallam, Grays Harbor,Jefferson, Name Kitsap, Mason, Pacific, and Wahkiakum (Please Print) James Mjor Jurisdiction Counties Phone (360)473-0101 E-Mail 'ames.m'or ws .wa. ov Restrictions Per the WAC and information provided in this application packet. 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 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 6 of 7 AUTHORIZED EMERGENCY VEHICLE PERMIT I A t ' WA:KMG M if An NET KUL 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 2008 9174491 SIREN WHELEN MAKE MODEL LAMP(S) (location/colors) HARLEY FLHTPI FRONT VIN REAR 1 HD 1 FMM 148Y651348 REGISTERED OWNER ❑ OTHER EQUIPMENT: BRADLEY PUBLIC SAFETY& SECURITY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2010 C19762T ® SIREN CJB 00 MAKE MODEL ® LAMP(S) (location/colors) CHEVY IMPALA FRONT UNDERCOVER VZ 2• VIN REAR TRAFF ADVISOR 2G 1 WD5EM6A 1233161 REGISTERED OWNER ❑ OTHER EQUIPMENT: BRADLEY PUBLIC SAFETY& SECURITY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2005 LEM9709 ® SIREN WHELEN MAKE MODEL ® LAMP(S) (location/colors) HARLEY FLHTPI FRONT WHELEN _ 3• VIN REAR WHELEN 1 HD 1 FHW 195Y668436 REGISTERED OWNER ❑ OTHER EQUIPMENT: MATTHEW STEINAUER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2009 7F1443 ® SIREN WHELEN MAKE MODEL ® LAMP(S) (location/colors) 4) HONDA ST1300 FRONT WHELEN VV I N REAR WHELEN JH2SC51749K600621 REGISTERED OWNER ❑ OTHER EQUIPMENT: BRADLEY PUBLIC SAFETY& SECURITY 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 6/15) Page 3 of 6