Loading...
AG 18-073 I I RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM . ORIGINATING DEPT./DIV: POLICE DEPARTMENT ORIGINATING STAFF PERSON: LYNETTE ALLEN EXT: 6701 3. DATE REQ.BY: ASAP TYPE OF DOCUMENT(CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT(E.G.,RFB,RFP,RFQ) ❑ PUBLIC WORKS CONTRACT 0 SMALL OR LIMITED PUBLIC WORKS CONTRACT ❑ PROFESSIONAL SERVICE AGREEMENT 0 MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT 0 HUMAN SERVICES/CDBG O REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT(E.G BOND RELATED DOCUMENTS) ❑ ORDINANCE 0 RESOLUTION ❑ CONTRACT AMENDMENT(AG#): 0 INTERLOCAL X OTHER PERMIT APPLICATION/AUTHORITY . PROJECT NAME: PERMIT APPLICATION/AUTHORITY FOR FUNERAL PROCESSIONS NAME OF CONTRACTOR: ELITE MOTOR ESCORT ADDRESS: PO Box 66897,BURIEN,WA 98166 TELEPHONE: 206-466-2161 E-MAIL: DAVEAELITEiMOTORESCORT.COM OR LEROYBARKER(Q MSN,COM FAX: SIGNATURE NAME: DAVE EADY TITLE: CEO EXHIBITS AND ATTACHMENTS:0 SCOPE,WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE 0 ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES 0 PRIOR CONTRACT/AMENDMENTS TERM: COMMENCEMENT DATE: 2018 COMPLETION DATE: 2019 '. TOTAL COMPENSATION$ N/A (INCLUDE EXPENSES AND SALES TAX,IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE-ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE:❑YES 0 NO IF YES,MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ❑YES 0 NO IF YES,$ PAID BY:❑CONTRACTOR 0 CITY RETAINAGE: RETAINAGE AMOUNT: ❑RETAINAGE AGREEMENT(SEE CONTRACT) OR 0 RETAINAGE BOND PROVIDE ❑ PURCHASING: PLEASE CHARGE TO: 0. DOCUMENT/CONTRACT REVIEW INITIAL/DATE REVIEWED INITIAL/DATE APPROVED ❑ PROJECT MANAGER ❑ DIRECTORL'""`? S/i//8 ❑ RISK MANAGEMENT (IF APPLICABLE) ❑ LAW V2L YpjtrS 1. COUNCIL APPROVAL(IF APPLICABLE) SCHEDULED COMMITTEE DATE: COMMITTEE APPROVAL DATE: SCHEDULED COUNCIL DATE: COUNCIL APPROVAL DATE: 2. CONTRACT SIGNATURE ROUTING O SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE,LICENSES,EXHIBITS ❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR 1 MONTH PRIOR TO EXPIRATION DATE (Include dept.support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.) INITIAL/DATE SIGNED ❑ LAW DEPARTMENT - SIGNATORY(MAYOR DIRECTO Ol��i ( (1 CITY CLERK O C aASSIGNED AG# I # SIGNED COPY RETURNED DATE SENT: o 1100, :OMMENTS: Inn] it / 'Ce ( �.• }'d �s�a • Chief of Police It is that time of year for permit renewal and so we are requesting your approval on this permit. We look forward to working with you and the comunity that serve as we have for years to provide safe transport of funeral processions in your jurisdiction. Since time is short we hope you will expedite this asap. Thank You, . Leroy Barker ermit Dir r Elite motor Escort ELITE MOTOR ESCORT INC. (206) 466-2161 "Your Safety Is Our Concern" AUTHORIZED EMERGENCY VEHICLE PERMIT LIMNINIA 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 (if a person, must list agency/department representing) Elite Motor Escort Address PO Box 66897 City Burien State WA Zip 98166 dave@elitemotorescort.com Phone (206)466-2161 E-mail leroybarker@msn.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. Assist local Funeral Directors and their"families" in a time honored tradition devoted to those that have Passed in procession of their loved ones to a place of internment while keeping the safety of the procession And general public at the forefront. RCW 46.37.194 Chapter 204-36 WAC WAC 308-330-446 WAC 204-36-050(3) 3000-323-006(R 8/15) Page 1 d AUTHORIZED EMERGENCY VEHICLE PERMIT II Il 111411•111k APPLICATION 6.-1 ,' --- 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 ,v001 LErn qiciL4 r] SIREN X k)..)he-kt `i tii?A 112_ MAKE MOD L 0 LAMP(S)(location/colors) Oar le-Y I- L t+T I' ' Rtii _sOu6D .5 -acf 1 ive_ Epp —DixD 1. VIN F Rok)+ Z_ eTzlr 1 I4D 1 Finn itil Y Vet--)(A-- REGISTERED OWNER 0 OT-HER EQUIPMENT: DH-VE Ea A y VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 200a. 1.-ely‘ 7400 0 SIREN u-itele_Aj tish-q4. 11 MAKE - MAKE MODEL I LAMP(S)(location/colors) For? Crowe q ic_i-ori 0- re_ci Fit-t ... 0-:)P 0 CC C.=P 0.56-Dai-D 2. VIN re A r-- c:t r tolvdt,tv ik $(c r-A FP-iitkitxx 1W/J.0(c, REGISTERED OWNER JZ HER EQUIPMENT: . , 3 (AO ule_le I.; 5-3O4 IP/L4 ,i ect r OR V -- E-acy VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 300 5 11-e-S 970 { 'SIREN 3h 0 rn'4' 30 Xi 01-1 MAKE MODEL 0 LAMP(S)(location/colors) i-karle, f 1-Vt TP i- i.k/ujilti-a--rear co ci.e,3 .p il-'I 0 3- VIN rt d Lea ,51-rcb e 614-Q- -thr-5& FLI 0/c 2. -1 H4DiF0111) 11-tg\ilp,513i-i? re 'i Frct%3 r u.)1-te.te-t-' Si 5 to(4 0 REGISTERED OWNER 0 OTHER EQUIPMENT: Rktri c.- k If°c.-I'N VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 00(i) 508E8 q RSIREN wklov 6/1.3141 MAKE, MODEL., LAMP(S)(location/colors) VtOtJCIU 6C-5 Side_Red ovvi-e- Luhe,le_t4 c2co p, 4. VINlitci F.129LN r iehe_l e.t,-1 wt../ 614 9-5 C.,5174/114002-c1"1 Rtct -5icle- h -( -r-' TI 8 (0 REGISTERED OWNER D OTHER EQUIPMENT:w h e,1 orre1- i+ jatLaeoz___-____ pOry,; 0 q +-or DNR )' (CM Note: This page may be copied if additional vehicles need to be added to the permit. Any additional sheets attached must provide the vehicle and equipment information in the same format as above. 3000-323-006(R 8115) Page 2 of% AUTHORIZED EMERGENCY VEHICLE PERMIT 5.9.11°,111h. 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 2-00(o It1/40 61 Li" EASIREN lidile_l C rst CUP fi- I MAKE MODEL [SLAMP(S)(location/colors) irk F 1— 14 1-Pr_ fkr A Fr 0 t C 0 d e. Pa r 4 g II VIN 1 14 D 1 FIN II&Y(4,87 0 I ,5- Re_eit tear 4,1ht-ItA\-) Tie- lo^ REGISTERED OWNER R OTHER EQUIPMENT: TO el VI est Conte rs VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE_ NO. INSTALLED MAKE MODEL 2_008 Lk: Pi S i 4'3 1,8 SIREN Wilt-it-n W5 32f) MAKE MODEL. /1 a A g LAMP(S)(location/colors) 1-kcir ie_v if:lee.b.-a c--- 1 icti- iv(i c•-'4 p_ect fro Ni 4- to h-e-lt,0 b0 r00)(irAcwoorr V •VIN I i-tDi fill' X 8)/ 686-665 Rta Rcar 560--MQ- II , 80000-5P REGISTERED OWNER 0 OTHER EQUIPMENT: Wif 1 0 C I CXYVe—N f Rfij .51'8-K. /elm to TrI)C Ic-L hz.51 sizi t Lia5-0 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED , MAKE 4, MODEL Di OC)1 0 D 7 750 r SIREN iiii fib I 5an Pihi(3 80Kao1)51'00 A MAKE MODELil, LAMP(S)(location/colors) .. Kettklattki KZ - 1O001' kt-,(I fro if (),) he I C lk-1 Pa r35 7 ' VIN JK A K LE:F 231861 9 I 4 7 8-ett , d-c_. -s-i-rekr& Trocil Lke- REGISTERED OWNER n OTHEAR EQUIPMENT: , R e a fiear....)frth-e--1—:rie- 6caiil Kennej-h Co 0 I _ VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL 2C08 1 0434 Len-, 0 SIRENLL? t)R L- MAKE MODEL _ LAMP(S)(location/colors) Isihtit'iv' go 1-kuritv Fu-IT r Ji-iK Erc.)6* wim-lt-, iv :Par_3 C U s VIN Vt d/4)k.1 t, t cir Lk;ke-t Cl‘i 1,110211#MOSCrIeS ii+Oirnlinicieit00-774, R•cJA,:iiii I-e• filVt-Allije.Sta-e- whele0 REGISTERED OWNER 0 OTHER EQUIPMENT: Tir lift I I-I-if:VOL:CV OFt 1 c-Drn 3 fn 54 rob e--- A 1,;(1ruj Cu rt er 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) ',op 3 AUTHORIZED EMERGENCY VEHICLE PERMIT ILI APPLICATION %or 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 a9(11LI d B34 2 SIREN UiKd ' 94350P'14 MAKE MODEL ❑ LAMP(S) (location/colors) 0 AiL vINrley 1 t f1 T"F Ret Fkot1 t - rt?c r b;)�/eN 1pA ,3 ) i i 14D 1 Fninf f)(1:-:130‘19 8 0 REGISTERED OWNER ❑ OTHER EQUIPMENT: , ,a�thtu- u5 o VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED iiM_ ``AKE MODEL !E a6`6-- in ci0Hp [SIREN (i!(lae iv .5f135 ) Mk MAKE MODEL ❑ LAMP(S) (location/colors) • IANriz' F Lit Tr rRoNt Red 6ihik rear ode p LN z_ i ti,DI FP Th IgFUIVt73 REGISTERED OWNER ❑ OTHER EQUIPMENT: Ect r I iacd 4o r d VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL ; 00B q 903 ii (SIREN OA eP 5A ,35-0 MAKE MODEL ❑ LAMP(S) (location/colors) I-\-61r1-ey F Lit Tr Bair Ig6P R=Qr oaiileP O Uj I(pI If D II III VIN I II 00I F 11 in 13 6i7009'68 REGISTERED OWNER ❑ OTHER EQUIPMENT: 1ojer 5k .rwe0ci VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL :km O t R i 1 I [24-SIREN (0 1t'les L,0 Pi"i-1I 21 MAKE MODEL ❑ LAMP(S)(location/colors) ItOIvc51`I ' 0(-)PA red i rrNi r wNe-le / t oFF RCJI©Q 1 S VIN n r_ / rc� u h.4 f roNt fthfer f_c( pt Tei S1-415c.„1-;171-1 "l K(Uo 4_?fit pad w h-,1-e- 5i k v.ke_t e_N I I R 3 REGISTERED OWNER ❑ OTHER EQUIPMENT: Ttri 0fhy 4' a()N./ Reck Rezi r i~yttz(eIi TIP 3 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 iggpLi AUTHORIZED EMERGENCY VEHICLE PERMIT MAIM 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 2_003 Li E7 -15.4 gr.SIREN W1'1 e—k 6 1`) 5t4 7150-111-I MAKE MODEL 41 LAMP(S)(location/colors) 1+4 r le/ r-71-14 TT i Lth FR_QN-t-g e-4 Pa r,3 L ,50-1D--Led ( .3 al VIN L_-e. a rcaffiec - reywh(-14- 00,fiaVer' aTIR _IAD 1 F•P1 LA)I u.yo:',24:Ai 5 REGISTERED OWNER rA OTHER EQUIPMENT: Le - 516 (ae- ( r-recephr kli._ 8 1- i g- e, oc,HRIkl‘i , JohNi Led raci i obck -r /wil t w LI ei,/ "76AC.‘ re- R VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL Gq01g, 6,e- 5 80.5 I -SIREN tUilPleiv 5-69,I OR MAKE MODEL fl LAMP(S) (location/colors) , Parley FL(417 r-ear A ED t utideN 7c)o Se-We-5 ( -j 0 VIN . i i401 FP/A(.)65( 078A 7ç r - k 0 ni r red u4 Id eiNi L j Po,r 3(0 REGISTERED OWNER OTHER EQUIPMENT:, • I Ke.iiiR01 L 0\ : C oc--- e_ . f . • •_red we_ttl,/ 6-00 5u--i e S r- r -tio 0 red. tuke-t e I-) 7 00 Serte.._.: VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. INSTALLED MAKE MODEL ' 0200 i (-roil L.Grn 0 SIREN MAKE hlEL - 0 LAMP(S) (location/colors) 15 0 VIN M31014 [ 814- (1 -70083 REGISTERED OWNER 11] OTHER EQUIPMENT: j - WiCAO /a 5 Eh 1 1 VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION YEAR LICENSE NO. . INSTALLED MAKE MODEL .z_co .2 5 A S (o _3 ' El.SIREN Ulve.in 14 ex- OS301, I MAKE MQDEL , , 0 LAMP(S) (location/colors KOW61,5( 4/0 ICCe IOU 0 fProN.1--- RfL) to il e, ci IN. kl -GSe_ril*0( [ 6, 110 VIN sot_ gQ et cci. e 11 1,si 1---4....Ttr 0 be. *- -J (+KV- P.2.Likff..511,5q 3 ‘pci LK. R t cit ccuoht- .,. Rea.14 bi44, REGISTERED OWNER 0 OTHER EQUIPMENT: bk-l-e •E+ i71 L.', • v- 17 in-otiv 4a uw . 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. 3000-323-0(E(R W15) Page Mb .5--- AUTHORIZED EMERGENCY VEHICLE PERMIT ER, _mamA. 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. Flagger Certification Number Name Driver's License Number New? (if applicable-see WAC 204-36-040) I. C/64ter Me/ t41 VIE COO-VG IV 0 Z . DPVI d rrap k demec431605 a xp.3-5-2025 NO 3. C-ookicgs we:WI Le-e- C..ociak L5 3,5:DK ,;z3/53 1 EYf35ZOZO KJ° Li. C.-urritr- 11 feu: 14tyko' Corr Lai-13-15W 33t-1a_L,o 5 Eaciy. DC\4 , Eaatoeseops 3390,43 C- 1. 3-S-Zoi.b 140 6. th -kiarnfkicilked37(03 F 339 a3 &cp. -Z0(8 i•10 7 i4 0(0 Forrest.- Holctif D'187/111 exp 09 - 101 1\1 0 a „IN Pidanee, nchgej kwiNkyro-Lt5tL-1 334)3S EA - 2 )l° NO 9. t_Ai ilaitheoi Lai 5om ta..c1 L(I 376076 Eqzi 7t WO IQ fleyerPcJa , illeyerpe 151 tcz... 331 x-P . 375-202O KID 11. Racl-r-Orci, earlilan I/ fo-e. 5 tics r.r 3-7q,2y4 E-xp 5-07/3 2.ck NJ 0 14 5herwood1 Ro,rte 5heruxa 500 33Li9e?cp. 3-5-22-c) Mc) 13 1-ka titt4 nit,thy 1-1 a vt-,4•Tvi)q 358338 GT 2.-,27-z6 tet J o 1(1- e_oahro IANArcus-L5, (oc.h rzt s 189 6 34S E- p, -51?1).2,c ye.5 0: 1JJc5 JM'19tR LI 2-44 EA, ye5 3000-323-006(R 8115) Paged. 7 AUTHORIZED EMERGENCY VEHICLE PERMIT ®® APPLICATION UM. 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. I i, ', l 174, City Streets (list all cities) Fe Ati- J a t 00, , ❑ County Roads (list all counties) ❑ State Routes/Interstates (list all state routes, interstates, and counties) 5. Permit Validation: I certify(or declare) under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct to the best of my knowledge, information, and belief, and that: a. All of the information given in this application is correct to the best of my knowledge and provided in its full format to the undersigned chief law enforcement officer or fire chief(if the vehicle is to be used for firefighting purposes)of each primary jurisdiction in which the vehicles are to be used as authorized emergency vehicle(s). b. None of the drivers,to the best of my knowledge, in the last year, have been convicted of, nor served any sentences or periods of probation for any felonies, nor arrested and convicted of a drug or alcohol violation or illegal use or possession of drugs, nor been required to register as a sex offender. c. Only the vehicle(s)and equipment listed in this application will be used as outlined in this application, and that only the operators listed under this permit will drive the vehicle(s). As the primary holder or executive officer in charge of overseeing this permit, I understand that if the permit is issued, it is my responsibility to ensure: a. No driver listed in this permit uses the vehicle for any purpose not authorized under this permit unless all emergency equipment is removed or covered. b. No driver other than those listed under this approved permit operates the vehicle(s)listed unless all emergency equipment is removed or covered. If I wish to add a new driver or vehicle to this permit, I must receive prior approval before they are authorized under this permit. c. The driver must exercise due care and caution and must obey all traffic laws. I understand that the inappropriate or misuse of authorized emergency vehicles may result in criminal or civil liability as well as cancellation of this permit as outlined under chapter 204-36 WAC. In addition, I understand that it is my responsibility to ensure that a copy of this permit listing all approved drivers and geographic areas authorized,as well as a copy of the vehicle permit authorizing emergency equipment is present in each vehicle at all times and must be presented to law enforcement, if requested. .. Signature ,� �' /� .� Title Perry)t t rec k-Or ar.,.1�i g � '/<ara Ve-6v-1 2)6id 0CHIE EXECUTICEf Q Name t,t��y ric r akve /� Date r'"'—i5 ' '� IS / �(TYP PRINT) 3000-323-006(R 8/15) Page 4 of 5 AUTHORIZED EMERGENCY VEHICLE PERMIT ®•GrOM oi N`ASHFS ti APPLICATION uuor 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 2.,.9. 7. - i Date Title c•r,G `t e3«o4E Name ' r '-'y L.L_,,�,4. Jurisdiction (Please Print) J ���+ A-sOrK.4-c 1✓4,0 Phone (.&s-p) 83 S— 7'4 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 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 1111 a v.` aa 1/4 �� ) I j —_ Vii► Contact information Elite Motor Escort CEO Dave Eady daveeady@msn.com (206)466-2161 BOD Member Doug Clark drelark3@hughes.net (360)275-5614 Permit Administrator Leroy Barker leroybarker@msn.com (206) 940-0523 • ELITE MOTOR ESCORT INC. (206) 466-2161 "Your Safety Is Our Concern"