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AG 23-244 - STEVEN JACOBSRETURN TO: PW ADMIN EXT: 2700 ID #: 4336 (Master Template - 4325) CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: PUBLIC WORKS / Deputy Director 2. ORIGINATING STAFF PERSON: Desiree Winkler EXT: 3. DATE REQ. BY: 11/17/23 3. 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) ❑ ORDINANCE ❑ RESOLUTION ❑ CONTRACT AMENDMENT (AG#): ❑ INTERLOCAL m OTHER Agreement Templates 4. PROJECT NAME: Relocation Agreement Template - 092104-9084 5. NAME OF CONTRACTOR: Steven Jacobs ADDRESS: TELEPHONE: E-MAIL: FAX, SIGNATURE NAME: TITLE: 6. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS CFW LICENSE # BL, EXP. 12/31/ UBI # , EXP. / / 7. TERM: COMMENCEMENT DATE: A lzo ``?7 _ COMPLETION DATE: 1 nir, 8. TOTAL COMPENSATION: $ 27,200 (INCLUDE EXPENSES AND SALES TAX, IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED: ❑ YES ❑ NO IF YES, $ PAID BY: ❑ CONTRACTOR ❑ CITY RETAINAGE: RETAINAGE AMOUNT: ❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDED © PURCHASING: PLEASE CHARGE TO: r36610-26110 9. DOCUMENT / CONTRACT REVIEW INITIAL / DATE REVIEWED INITIAL / DATE APPROVED 6 PROJECT MANAGER 6 DIVISION MANAGER 6 DEPUTY DIRECTOR DSW 11/14/23 6 DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) 8 LAW DEPT KVA 11/17/2023 10. COUNCIL APPROVAL (IF APPLICABLE) SCHEDULED COMMITTEE DATE: COMMITTEE APPROVAL DATE: SCHEDULED COUNCIL DATE: COUNCIL APPROVAL DATE: 11. CONTRACT SIGNATURE ROUTING ❑ 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 ❑ FINANCE DEPARTMENT ❑ LAW DEPT kZ0GNATORY (MAYOR Q [R[:CT ]- ,,<CITY CLERK o ASSIGNED AG # # w ❑ SIGNED COPY RETURNED TE SENT: COMMENTS; EXECUTE, 1-'ORIGINALS' 1/2020 Move Expense Agreement Residential Project Title: City of Federal Way, Joint Operations and Maintenance Facility Property Parcel No.: 092104-9084 Displaced Person(s): Steven Jacobs as Personal representative Displacee No.: 6 I, the undersigned, hereby certify that I am the owner of certain personal property that is lawfully located upon real property acquired in connection with the foregoing public works project. As a result of the acquisition, said personal property must be moved from the acquired site. By initialing below, I hereby select the following type(s) of moving option(s), authorized under the Washington State Relocation Assistance Program: Commercial Move. I will select and contract with a commercial mover to move all personal property onsite. Upon request, the INSERT AGENCY NAME (Agency) may make direct payment on my behalf to a qualified commercial mover to relocate my personal property up to a maximum of 50 miles. I estimate the value of my personal property to be $ . This amount will be used to determine the cost of my replacement value insurance (copy of insurance policy may be requested). I may be required to move flammable materials/chemicals/open containers (refrigerator items, pantry items, under sink items) that the moving company cannot move. If I do, I will be reimbursed a total of $ once the move is complete. Self -Move Actual Cost. I will move all personal property owned by me using my own resources and be reimbursed the actual and reasonable moving cost as documented by paid receipts, invoices, or other reasonable evidence of expense. Self -Move Scheduled Payment. I will move all personal property, owned by me, from the acquired site. Upon satisfactory completion of the move, I will claim the amount of $27,200 for 90 rooms. NOTE: Failure to comply with the terms and conditions of this agreement may result in denial of all or part of your claim for moving expenses. In the event that all per 'nal property is not removed, appropriate action will be taken by the Agency, and you will b r�5ponsible for the cost 1 ed with removing personal property left at the displacement site. This cost will be ed cted from your mo cla' (payment. JQ 3 Steven �� Relocation Specialist: Paula Ferreira -Smith, R/W-RAC ft-Y s.q Uby EJ W.1 PE DN L 2/Kiti E=S rUsn,®alyPllMer 'cam o=Gr d Pcderol Way, OU-PYUIiL Agency Authorization: EJ Walsh, P.E. Director of Public Works LPA-540 Rev. 10/21 Date '/D //3 /�a;Z 3 Date 11/20/2023_ _ Date AdUL w, Washington State Residential Room Count Department of Transportation Project Title: City of Federal Way, Joint Operations & Maintenance Facility Parcel No.: 6 Displaced Person(s): Heirs and Devisees of Sarah Jacobs, deceased Occupant: Steven Jacobs Displacee No.: 092104-9084 Displacement Address: 30902 28th Ave S, Federal Way, WA 98003 Inspection Date:7/28/2023 Number of Rooms: -Description Total Number of Rooms: 90 Scheduled Move Payment: $27,200 Adw � Washington State Residential Room Count VI/ Department of Transportation Adw woWashington State Residential Room Count Department of Transportation Adw � Washington State wI/ Department of Transportation Y •� El Main [ i v i n ,, Room -Art Residential Room Count f Washington State w, Department of Transportation r ys � ti �k _79 Family Room -With freestanding fireplace Residential Room Count f Adw Washington State Department of Transportation Residential Room Count Almok Washington State wo Department of Transportation •sa��_ , Residential Room Count Admk woWashington State Residential Room Count Department of Transportation Adw Washington State Residential Room Count VAWDepartment of Transportation - l•�' 7 -• i mow. AdmkL wA#Washington State Residential Room Count Department of Transportation Amok woWashington State Residential Room Count Department of Transportation Adw Washington State Department of Transportation \ �orage Shed AML � Washington State Residential Room Count A Department of Transportation AdElk Washington State Residential Room Count Department of Transportation AINAL Washington State wo Department of Transportation AIL Master Bed Handrail Residential Room Count CWWashington State Residential Room Count Departrnent of Transportation rb.-.-ga Master Bedroom BEDROOM 2 BEDROOM 3 AMIkk � Washington State Residential Room Count WIf Department of Transportation Adw Washington State w. Department of Transportation Paula Ferreira -Smith Relocation Residential Room Count Approval: Dang Rodriguez Date: