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Home My WebLink AboutCAG2018-0336 - Supplement - Elite Funeral Escort - Authorized Emergency Vehicle Permit Application - 06/21/2022 AUTHORIZED EMERGENCY VEHICLE PERMIT w-u+ .wrs�r A ra,z wrno APPLICATION DATE APPROVED VALID UNTIL: CAPTAIN: WASHINGTON STATE PATROL 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 BRADLEY PUBLIC SAFETY dba ELITE FUNERAL (if a person, must list agency/department representing) 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 AUTHORIZED EMERGENCY VEHICLE PERMIT W5M APPLICATION r 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 MAKE MODEL VIN INFORMATION ON FILE REGISTERED OWNER 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 MAKE MODEL VIN INFORMATION ON FILE REGISTERED OWNER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2009 7F1443 _ MAKE MODEL HONDA ST1300PA_ VIN INFORMATION ON FILE JH2SC51749K600621 REGISTERED OWNER 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 8/15) Page 2 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT °a®ra�f: APPLICATION n 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 I D434 MAKE MODEL H/D FLHTP VIN INFORMATION ON FILE 1 HD1 FMM198Y607796 _ REGISTERED OWNER ANDREW CURRIER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2014 C52447W MAKE MODEL FORD TAURUS VIN INFORMATION ON FILE 1FAHP2MK4EG127814 _ REGISTERED OWNER BRADLEY PUBLIC SAFETY &SECURITY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL MAKE MODEL VIN INFORMATION ON FILE REGISTERED OWNER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO, INSTALLED MAKE MODEL 2008 9143LEM MAKE MODEL H/D FLHTP1 _ VIN INFORMATION ON FILE 1 HD1 FMM1 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 °6®G0„6 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 2012 BHX0384 MAKE MODEL ,DODGE CHARGER VIN INFORMATION ON FILE 2CICDXAGOCH295580 REGISTERED OWNER JACOB BRADLEY VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2021 C46295X MAKE MODEL DODGE DURANGO _ VIN INFORMATION ON FILE 1C4RDHFG1MC640673 _ 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 C52069W 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 6115) Page 4 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT ®G SFiF[i%iROS APPLICATION R 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 MAKE MODEL VIN INFORMATION ON FILE REGISTERED OWNER 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 METROPOLITAN RAILROAD CORP VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL MAKE MODEL VIN INFORMATION ON FILE REGISTERED OWNER VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2005 C51611 V _ 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 I9&NMI 7 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 2009 C32235U MAKE MODEL CHEVY TAHOE VIN INFORMATION ON FILE 1 GNEC030X9R259815 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 2C3CDXAT9JH221391 REGISTERED OWNER DAVID CLEMENTS VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2021 C46025X MAKE MODEL DODGE DURANGO VIN INFORMATION ON FILE 1 C4RDHFGXMC640672 REGISTERED OWNER METROPOLITAN RAILROAD CORP VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO, INSTALLED MAKE MODEL 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. 3000-323-006(R 8115) Page 6 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT O !=op 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 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 056220286 ATSSA confirmed (card on file) JAMES GREENE WDL3NNZ9J23B ATSSA confirmed (card on file) SCOTT GERBER GERBESM116R9 ATSSA confirmed (card on file) ANDREW CURRIER CURRIAH375NA 232531 JACKSON CHANG WDL58NRD073B ATSSA confirmed (card on file) TIMOTHY HAUN HAUN*TL419KD 358338 PATRICK HOCK HOCK*3765JP 386021 ROBERT NUNES WDL21758813B ASCWZF20503 DAVID CLEMENT CLEMEDF3780S 232529 ETHAN SCOTHORN WDLBZ3B3853B 01900360 WHITNEY NELSON WDL5S49B823B ASWZF0200069 3000-323-006(R 8/15) Page 7 of 9 AUTHORIZED EMERGENCY VEHICLE PERMITS APPLICATION 4. Geographic Area: Indicate which types of roads and which specific geographic area(s)the authorized emergency vehicles will be used. Certification from each jurisdiction is required under WAC 204-36-030. Certification is covered in section 6 of this application. ® City Streets (list all cities) 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. Signature94!r�� I Title CEO Cl (CHIEF EXECUTIVE D ICER) Name JACOB BRADLEY Date 06/07/2022 (TYPE OR PRINT) 3000-023-006(R 8/15) Page 8 of 9 AUTHORIZED EMERGENCY VEHICLE PERMIT MINGTM%TA a. APPLICATION tLor. 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 �-�l--- Title 64I Name(Please Print) Jurisdiction _ t RU U Ge- 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 Jurisdiction (Please Print) 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. Page 9 of 9 3000-323-006(R 8/15)