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HomeMy WebLinkAboutCAG2018-0336 - Supplement - Elite Funeral Escort - Authorized Emergency Vehicle Permit Application - 06/21/2021 FOR CITY OF KENT OFFICIAL USE ONLY Sup/Mgr: Agreement Routing Form Dir Asst: • For Approvals,Signatures and Records Management Dir/Dep: KE N T This form combines&replaces the Request for Mayor's Signature and Contract Cover (Optional) WASHINGTON Sheet forms. Originator: Department: Jalene King Police Date Sent: Date Required: > 09/22/2021 0 i CL Authorized to Sign: Date of Council Approval: QDirector or Designee Budget Account Number: Grant?E]YesE]No N/A Budget?E]YesEl No Type: N/A Vendor Name: Category: Elite Motor Escort Application Vendor Number: Sub-Category: = Original 0 Project Name: Emergency Vehicle Application E 0 Project Details:authorized emergency vehicles _ a� E Agreement Amount: Basis for Selection of Contractor: Direct Negotiation *Memo to Mayor must be attached i Start Date: Termination Date: im Q Local Business?F--]YesF--]No* If meets req uiremen ts per KCC 3.70.100,please complete'Vendor Purchase-Local Exceptions'form on Cityspace. Business License Verification:ElYes In-Process Exempt(KCC 5.01.045) Notice required prior to disclosure? Contract Number: CAG 2021-416 F]YesF]No Comments: _ :1w 3 0 d H •� i N 3 M _ a1 V1 Date Routed to the City Clerk's Office: ac�emn3�i__ro Visit Documents.KentWA.gov to obtain copies of all agreements rev.20210513 AUTHORIZED EMERGENCY VEHICLE PERMIT o 0 0© SHINGTON STAGE MTNOL APPLICATION U'+, �I,, DATE APPROVED: 6/28/2021 VALID UNTIL: /28/2022 CAPTAI 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, orAgency (if a person, must list agency/department representing) BRADLEY PUBLIC SAFETY dba ELITE FUNERAL ESCORT Address 15609 CEDAR GROVE ROAD NE City POULSBO State WA Zip 98370 Phone (478) 228-7544 E-mail bradleypss@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 WAC 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 thru 065. 3000-323-006(R 8/15) Page 1 of 9 From:Jacob Bradley<bradleypss@outlook.com> Sent:Thursday, May 27, 2021 3:34 PM To: Mathis, Kimberly(WSP) <Kimberly.Math is@wsp.wa.gov> Subject: Re: EME_AEVP Permit This is approved. Please let me know if you need anything else. Jacob Bradley(#558), Founder & CEO Bradley Public Safety Group, LLC. bradleypss@outlook.com (478)228-7544 "Excellence. Pride. Courage." From: Mathis, Kimberly(WSP) <Kimberly.Mathis@wsp.wa.>ov> Sent:Thursday, May 27, 2021 3:33 PM To:Jacob Bradley<bradlevpss@outlook.com> Subject: RE: EME_AEVP Permit With your approval, the company name will be changed to Bradley Public Safety dba Elite Funeral Escort. Thank you, V-.W�uj Kimberly Mathis I Legislative Analyst WASHINGTON STATE PATROL I Government&Media Relations PO Box 42600 1 Olympia,WA 98504-2600 Office:(360)596-4017 Work Cell: (360)970-8205 From:Jacob Bradley<bradlevpss@outlook.com> Sent:Thursday, May 27, 2021 3:29 PM To: Mathis, Kimberly(WSP) <Kimberly.Mathis@wsp.wa.gov> Subject: Re: EME_AEVP Permit Ahhh I just changed it on the permit application. To Whom it May Concern at WSP: Please modify the company name on our permit to reflect the following: Company: Elite Funeral Escort Address: 15609 Cedar Grove RD NE, Poulsbo, WA 98370 Phone: 478-228-7544 Owner: Jacob Bradley UBI#: 603-609-693 E- Mail: bradleypss@outlook.com All other information remains the same. Jacob Bradley(#558), Founder & CEO Bradley Public Safety Group, LLC. bradleypss@outlook.com (478)228-7544 "Excellence. Pride. Courage." AUTHORIZED EMERGENCY VEHICLE PERMIT WASHINGTON APPLICATION ,war 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 MAKE MODEL FORD CROWN VICTORIA VIN INFORMATION ON FILE 2FAF971W12X127206 REGISTERED OWNER DAVID EADY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL Me&--------9-2-2�JL+FA removed MAKE MODEL 9/7/2021 W-D--------- � �R� VIN INFORMATION ON FILE +Ha f-N91444BY65+346 REGISTERED OWNER PATRI I I lJl. //l\ VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2005 LEM9709 MAKE MODEL H/D FLHP1 VIN INFORMATION ON FILE 1 HD1 FHW195Y668436 REGISTERED OWNER MATTHEW STEINAUER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2009 OE8191 MAKE MODEL HONDA ST1300PA VIN INFORMATION ON FILE JH2SC51749K600621 REGISTERED OWNER TIMOTHY HAUN Note: This page maybe 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 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT WASHINGTON APPLICATION ,war 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 434LEM MAKE MODEL H/D FLHTP VIN INFORMATION ON FILE 1 H D 1 FM M 1987607796 REGISTERED OWNER ANDREW CURRIER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL removed - � 9/7/2021 MAKE MODEL 4/-D--------pinw-TR� VIN INFORMATION ON FILE *+D+FMW492u?6N?-+§ REGISTERED OWNER AP�D{�1Ay,4�1-IL{�F�-0E4-I VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2006 9AO874 MAKE MODEL H/D FLHP1 VIN INFORMATION ON FILE 1 H D 1 FH W 116Y687015 REGISTERED OWNER MELVIN J. CENTERS VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2008 9143LEM MAKE MODEL H/D FLHTP1 VIN INFORMATION ON FILE 1 H D 1 FM M 1 X8Y685665 REGISTERED OWNER DAVID CLEMENT 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 9 AUTHORIZED EMERGENCY VEHICLE PERMIT WASHINGTON APPLICATION ,war 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 2012 BHX0384 MAKE MODEL DODGE CHARGER VIN INFORMATION ON FILE 2C3CDXAGOCH295580 REGISTERED OWNER JACOB BRADLEY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2021 C46295X added MAKE MODEL 8/18/2021 DODGE DURANGO VIN INFORMATION ON FILE 1 C4RDH FG 1 MC640673 REGISTERED OWNER METROPOLITAN RAILROAD CORP VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2013 C06817P MAKE MODEL FORD TAURUS VIN INFORMATION ON FILE 1 FAHP2M80DG113556 REGISTERED OWNER BRADLEY PUBLIC SAFETY & SECURITY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2014 C52069V MAKE MODEL FORD TAURUS VIN INFORMATION ON FILE 1 FAHP2MT7EG148262 REGISTERED OWNER 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 8/15) Page 4 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT WASHINGTON APPLICATION ,war 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 2003 BOH2O65 MAKE MODEL DODGE DURANGO VIN INFORMATION ON FILE 1 D4HS48N33F596553 REGISTERED OWNER JACOB BRADLEY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2015 C32236U MAKE MODEL CHEVY TAHOE VIN INFORMATION ON FILE 1 GNSK3EC4FR570800 REGISTERED OWNER JACOB BRADLEY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2010 C19762T MAKE MODEL CHEVY IMPALA VIN INFORMATION ON FILE 2G1 WD5EM6A1233161 REGISTERED OWNER BRADLEY PUBLIC SAFETY & SECURITY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2005 C51611V MAKE MODEL FORD CROWN VICTORIA VIN INFORMATION ON FILE 2FAFP71W25X164141 REGISTERED OWNER 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 8/15) Page 5 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT WASHINGTON APPLICATION ,war 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 2009 C32235U MAKE MODEL CHEVY TAHOE VIN INFORMATION ON FILE 1GNEC030X9R259815 REGISTERED OWNER METROPOLITAN RAILROAD CORP VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2018 BMM9950 MAKE MODEL DODGE CHARGER VIN INFORMATION ON FILE 2C3CDXAT9J H221391 REGISTERED OWNER DAVID CLEMENTS VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2011 C5207OW MAKE MODEL FORD CROWN VICTORIA VIN INFORMATION ON FILE 2FABP7EV2BX153734 REGISTERED OWNER BRADLEY PUBLIC SAFETY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2014 C52447W MAKE MODEL FORD TAURUS VIN FAH P2MK4EG127814 INFORMATION ON FILE REGISTERED OWNER 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 8/15) Page 6 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT oo ■ WgSNINGTON STATE RRTR\ APPLICATION uor 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 2021 C46025X MAKE MODEL DODGE DURANGO 1. VIN INFORMATION ON FILE 1C4RDHFGXMC640672 REGISTERED OWNER METROPOLITAN RAILROAD CORP 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 2 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT o 0 0© SHINGTON STAGE PATROL APPLICATION U'+, �I,, 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 204-36-040) JACOB BRADLEY BRADLJD087B5 JAMES GREENE WDL3NNZ9J23B SCOTT GERBER GERBESM116R9 ANDREW CURRIER CURRIAH375NA 232531 MELVIN CNETERS CENTEMJ422RG 232532 A++DR-EW£9E:-I4RA++ GGC-+ER-A§a$t3K-B- �q!42,t5------------ 9/7: removed PATRICK HOCK HOCK*PW376JP 386021 MATTHEW STEINAUER STEINMR483NZ 334241 DAVID CLEMENT CLEMEDF3780S 232529 �,4VA-9- y------ -E-ArDy--2LDE-590&5--- 334,243--------------- 8/10: remove TIMOTHY HAUN HAUN*TL419KD 358338 ETHAN SCOTHRON WDLBZ3B3853B 01900360 WHITNEY NELSON WDL5S49B823B ASWZF0200069 ROBERT NUNES ASCWZF20503 ANTWON BYRD ASCWZF20372 3000-323-006(R 8/15) Page 7 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT o 0 0© SHINGTON STAGE MTNOL APPLICATION U'+, �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) PUYALLUP, SUMNER, FIFE, AUBURN, KENT, SEATTLE ® County Roads (list all counties) SKAGIT, THURSTON, KING ® State Routes/Interstates (list all state routes, interstates, and counties) D8 (HWY 3, HWY 303, HWY 101, HWY 308, HWY 305) D1 (1-5, 1-405, SR-167, SR-515, SR-16, SR-3) 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 Title CEO (CHIEF EXECUTIVE OFF ER) Name JACOB BRADLEY Date 05/11/2021 (TYPE OR PRINT) 3000-323-006(R 8/15) Page 8 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT m X M1tea 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 o'�I`� ►�z l Title Name D Z(�N A11 d �T(Please Print) Z - `y\ Z-- Jurisdiction CITY OF SEATTLE Phone (7f/U.) SSS E-Mail aok v--rLn -rA f?A-e- • ,n)k, 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 an e) Page 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT Rill ''°'�_ 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 veh}cle(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: r Signature �f�^-�-� �'� Date �-Z1=2 f Title Ck t_� P-f= PoL,cF_ Name 2 ` � (Please Print) `✓R' l;'l�(—�1 � Jurisdiction 1T O�= ! �w4Na:f2_ Phone _(2�3 ) 29R -S1Py t E-Mail bf-A'b M C S aJxf . a Lvr- 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 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 8/15) Page 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION tw. d. Certification: This application for an Authorized Emergency Vehicle Permit wlli not be accepted unless CERTIFIED by the chief law enforcement officer or fire chief of the vehicle is to be used for firefighting purposes)of each primary jurisdiction in which the vehocle(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-d► isoon The certification must include the following language 'I hereby certify that I have reviewed this entire application. that I am aware that the appl"nt intends to use the vehicle(s)and emergency equipment listed in part 2 of this application. for the specific purposes listed in part t of this application, that a need exists in my jurisdiction for the listed vehicle(s) to be used as &A wrized eme h►cles and that the applicant has the appropriate authority as described in part t of thin appbcat►on o t u h equipment. and I know of no reason why this application should be darned ' Please type or print Signature Date du ItI Title (%iel nG filliCe Name ,,,, f"ej ,r, sit, Jurisdiction �;T� ►n Phone et; E-Mail Restrictions _ us��Ltt tall bra cc._s.�9�N l Av Signature Date Title Name Jurisdiction Phone 1 ► E-Mail Restrictions Signature Date Title Name r'r w.r.+ Jurisdiction Phone i ► E•Mail Restrictions Signature Date Title Name Jurisdiction Phone ► E-Mail Restrictions Signature Date Title Name Jurisdiction Phone i E-Mail Restrictions Signature Date Title Name Jurisdiction Phone S—.1_ 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 WW=400104% Page 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION •. CerWication: This appacabw for an AuttxwUed Emergency Vehicle Permit will not be acrept+ed unless CER TIFIED by the chief taw eMorosrnent officer or fire Chef(d the vehx:Je is to be used toil t'i Nhtmg purposes)of each primary pinedreoon in which the vehicWs)we to be used as authorized emergency veh,cin (see part 4 of this appbcabon) If the appbcat,on is made by the chief of a law enforcement agency or f.re department. it must be CERTIFIED by the head of the political sub-drwsion The certification must include the following language I hereby c&" that I have reviewed this entire appbcation that I am aware that the applicant k"nds to use the vehC*S)and emergency equ91)ment Irstld in part 2 of this appllico n, for the specific purposes listed in pan t of this appacatKon that a need erests in my)unsd+cbon for the Iested vebocWs) to be used as sutmortzed emergency vehcdes and that the appMcant has the appropnste authority as described in part t o! this aPPKatw to op)efate such enwpment. and 1 know of no reason why this appl"t,on should be den►ed Pease type or prim[ Signature / Date � )( Title / o&c �/e/ Name t � Jurisdiction Phone (!Ia) I • 00 E-Mail flodo .. "&w,0de Restrictions" Signature Date Title Name Junsdiction Phone E-Mad Restrictions Signature Date Title Name _ JurWicdon Phone i i E•Mail . Restrictions Signature Date Title Name Jurisdiction Phone i E Mail Restrictions Signature _ Date Title Name r, ". Jurisdiction Phone ► E-Mail Restrictions Signature Date Title Name Jurisdiction Phone f E-Mail Restrictions Note: The pipe may be copied d additlonai cen t+catrons need to be added to the permit Any addeonal sheets attached must provde the cendication information in:he same format as above � I A„e Ppe 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT ®9a 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 ,d, W ,. Date X.2y.z1 Title C dIC �/1Ce Name G p "� 1 C. (} I (Please Pont) 5�► - '�ncfG Jurisdiction 4 1 ...a `04\Cs 1/C� wtl� Phone (2j3$ �i3�5, 3�5� E-Mail Restrictions I;1fij��.u. 'PR fat! U)* li6" 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 Pont) 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-M6(R 8115) Page 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT °_SXIXLL X:TaiF Fli WG. APPLICATION - �f 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 t: Signature Date S I Title �4 PC)U G P0 Name Fic�o F1 ,5�,^K Jurisdiction f4 � PO i.C-C-77 Q L�fi (ReasePnnQ - Phone E-Mail Restrictions U r Signature Date Title Name (Please Print) Jurisdiction Phone { ) E-Mail Restrictions Signature Date Title Name iPiease Put] Jurisdiction Phone t ) E-Mail Restrictions Signature Date Title _ Name (Please Print) Jurisdiction Phone ( ) E-Mail Restrictions Signature _ Date Title _ Name (PleasePrind Jurisdiction Phone ( E-Mail Restrictions Signature Date Title Name — - - (Please Print) Jurisdiction Phone i I 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 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT o©o© WASHINGTON STATE PATROL APPLICATION U=7 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: Signatur7eaM20,1%%�/4AD ate 0PV Ar/' ?Title Name /V1 Jurisdiction 41iNG (Please Print) � •4'� G' ��r7I✓��,��/�'� r®e/yw' Phone �20G ) (D Z.S--K.S-°- 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 Signature Date Title Name (Please Print) Jurisdiction 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 8/15) Page 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT APPLICATION UJW 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 S Title upb,69ty&Z fFF Name (Please Print) PLAY a y Jurisdiction T k-SMpi ",it-3Ty Phone (Zo ) '7f6- SSoo E-Mail /LAY. 6QADY le co.T/v4SM0 . wA- uS Restrictions Fu► f4AL. ESGog-S ps _y 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 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT °®GTUH SLATE VATRUL 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__ ' 1V1,`�.�>,,.a(/� Date 5-12-2021 Title Sheriff Name Don McDermott Jurisdiction Skagit Count (Please Print) g y Phone ( 0S_t9t t E-Mail donmc@co.skagit.wa.us Restrictions Please advise Traffic Sgt. Willard of any events within Skagit County. ieffreyw(D_co.skagit.wa.us 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 (Please Print) Jurisdiction Phone ( ) 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. 3000323-006(R 8115). Page 9 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT ©g®6,oNs®® 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 -� 44 Date 05/12/2021 Title Captain Name or M (Please Print) James i Jurisdiction Captain, District 8—Bremerton Phone ( 360 ) 473-0101 E-Mail james.mjor@wsp.wa.gov Restrictions Limited to State Route's in District as listed on page 8 of 9. Signature ��� - Date i - Title c_,PA-et n Name (Please Print) Jurisdiction__0t-_kr<<--L I Co,yjE-, Phone ( 53 ) 538 -31a E-Mail o-z�hannorn C-t� wsQ,W A.G-&,f Restrictions Ltm%k,_( ko t��aa s -4c\ -\,,D k­k `- ck tt 5V_C� Cr, V�k�,� $ . 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 Pdnt) 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 9 of 9