HomeMy WebLinkAboutAG 12-136 - WA STATE DEPT OF TRANSPORTATIONRETURN TO: ��l�..� � EXT:
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
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TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ�
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG
� REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
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IS SALES TAX OWED: ❑ YES Je'NO IF YES, $ PAID BY: O CONTRACTOR ❑ CITY
t�' PURCHASING: PLEASE CHARGE TO: 3 ����yv� "� y Z- S`�S - 3 0`�S Z CJ
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❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
❑ LAW DEPT
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± Washington State
��Department of Transportation
Paula J. Hammond, P.E.
Secretary of Transportation
Northwest Region
Local Agency & Development Services
15700 Dayton Ave. N
P.O.Box 330310
Seattle, WA 98133
APPLICATION FOR JA ACCOUNT
Marwan Salloum, P. E. Deputy Public Works Director
City of Federal Way
Public Works Department
33325 Eighth Avenue South
Federal Way, WA 98003
Subject: SR 509
Dear Mr. Salloum:
MP 11.49 vic.
May 10, 2012
A charge account number, JA-7774, has been opened by this office to cover WSDOT's actual costs for reviewing
and commenting on submitted engineering data and plans, as well as construction inspection.
By filling out and signing the application, City of Federal Way Public Works, agrees to pay all WSDOT costs
related to your proposed improvement, including administrative costs unril this project is accepted by WSDOT as
complete. Please do not send funds at this Nme, an invoice will be submitted to �ou each month with the
charges that are incurred. Payment is due within 30 days of receipt of each invoice. Interest of 1% per month
may be charged on past due accounts.
--___
City of Federal Way Public Works
Developer Agency Name
33325 Eighth Ave South
Billing Address
Suite or Office Number
Federal Way, WA 98003
253-835-2720
Phone Number
91-1462550
Federal ID Number or SSN
Cary M. Roe, P.E.
Authorized Representative (Please Print or Type)
Director of Parks, Public Works and
Emer enc Mana ement
TiUe
f�" l
To avoid delays, please return this completed application as soon as possible, to the following address:
Washington State Department of Transportation
Attention: Felix Palisoc
Local Agency and Development Services, MS 240
P.O. Box 330310
Seattle, WA 98133
If you have any questions, please feel free to contact Felia� Palisoc, of our Local Agency and Development
Services section at (206) 440- 4713 or via email at palisof@wsdot.wa.gov.
Sincerely,
Ramin Pazooki
Local Agency and Development Services Manager
For Department Use Onty
Felix Palisoc / 412463
az Dash Point Road Intersection Improvemerts
JA-7774
tzcn.ao�
0910
