Loading...
AG 12-136RETURN TO: ��l�..� � EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: PUBLIC WORKS /��/' .�� /3 2. ORIGINATING STAFF PERSON: -� �J Ir� (� �" K1 I��"' P 2j ExT: Z 7 Z Z 3. DATE REQ. BY: �%}' � 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 AMEN�jD T(AG#): ❑ I/N�TERnLO�CAL � ` ��THER � /T GCi9us 1` Anoli� �m-c � I'�1� �I'�� �SJn�% .Qe✓iw �1hSfwrT.l.,�-. PROJECT NAME: � � S' � L � S'i�Y' ��- f � � '�J �.5 �. �Go ; .�, � /� ��. �i( "G vt {v� sP_ r �''� " �w A r0 i.G we �--ll , NAME OF CON RA ADDRESS: � E-MAIL: SIGNATURE NAME: Li Seµ Fa,�c: TITLE: --�i9a�S�) EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES O 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. / / TERM: COMMENCEMENT DATE: �9��� �X�GV J�' �`^ COMPLETION DATE: U� o� �H-P ��� �� •-� TOTAL COMPENSATION: $%i, �� O D (INCLUDE EXPENSES AND SALES TAX, IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES� REIMBURSABLE EXPENSE: ❑ YES L�l:NO IF YES, MAXIMUM DOLLAR AMOiJNT: $ 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 10. DOCUMENT / CONTRACT REVIEW @' PROJECT MANAGER R �DEPUTY DIRECTOR �DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) ❑ Law DErr IIVIT[AL / DATE VIEWED 5 � s i6 � � Z. lj. t'g{;�� Apvunve�,q�,-��� COMMITTEE APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING �vSENT TO VENDOR/CONTRACTOR A-�-I'�/' `� ' y r' '� DATE SENT: �l2' Z II Z- ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS ❑ LAW DEPT SF,YSIGNATORY (�6R DIRECTOR) ❑ CITY CLERK o ASSIGNED AG # ❑ SIGNED COPY RETURNED ❑ RETURN ONE ORIGINAL " I " ORIGINALS /"`�I I �%S � � l.lJ< � 5� l% � i�.� i,n i, INITIAL / DATE SIGNED S 2, � AG# J�-�?il� DATE SENT: �� � INITIAL / DATE APPROVED COUNCIL APPROVAL DATE: DATE REC'D: �o 111� ± 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