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AG 14-006RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIv: PRCS / 2. ORIGINATING STAFF PERSON: K I iM."I Sly EXT: Qftl 3. DATE REQ. BY: %-')I 1 L 4. 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 Cl RESOLUTION ❑ �CONTRACT AMENDMENT (AG #): ❑ INTERLQCAL �3LI�j�►� '�CI.6 ✓ jj) i/l.at faM, 7nw �y fc�A � 6C� �l�✓� 5. PROJECT NAME: - �(.I 1111 f4��. + d"A4Q } - 6. NAME OF CONTRACTOR: S —� �I' ADDRESS: 3 Z-L Z 'p 5� �� s k (Q�j I �) `1 �V� ELEPHONE: z5 3- V6 - o6o 11 E -MAIL: FAX: SIGNATURENAME: mb✓,�G.v, �� F�.I►_ TITLE: y �c-iV✓ 7. 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 # iBL, EXP. 12/31/ UBI # , EXP. 8. TERM: COMMENCEMENT DATE: 1 ' ` (� COMPLETION DATE: 1-a-14 9. TOTAL COMPENSATION: $ (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 ❑ PURCHASING: PLEASE CHARGE TO: 10. DOCU / CONTRACT REVIEW 6 PROJECT MANAGER ❑ SUPERVISOR • DIRECTOR • RISK MANAGEMENT (IF APPLICABLE) • LAW DEPT 11. COUNCIL APPROVAL (IF APPLICABLE) INITIAL / DATE REVIEWED eAS 4 COMMITTEE APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS • LAW DEPT • SIGNATORY (MAYOR OR DIRECTOR) • CITY CLERK • ASSIGNED AG # • SIGNED COPY RETURNED ❑ RETURN ONE ORIGINAL COMMENTS: Lemou has watvo'� INITIAL/ DATE SIGNED AG# I Li DATE SENT. eauc INITIAL / DATE APPROVED COUNCIL APPROVAL DATE: DATE REC'D: w LP 1/9 FRCVM :BALL CHIROPPRACTIC CENTER FAX NO. :2536613610 Jan. 03 2014 02:06PM P2 FEDERAL WAY FAMILY. HEAL "i('H & SAF'FTY FAIR INDEMNIFICATION AND I-NSI,1RANCE AG: EEMi This Indemnification.attd lusumnce.A (, greerxtent) is dated effi dive the'latirr date greetr►ent "A " 'itrdicated below with the signature. The parties•( "Parties ") to this Agreementare the City of Federal Wad+, 'a 'Washington municipal corpc»ilion ( "City ") and a ("Health Care Provider "): A= • the Health Care wishes to contribute services ,for'th. Federal 'Way 1?atnily Health & S il'ety Fai. ph JMuary :18;- .2014 ;. and B. The City wishes• tb .cooperatelby'allawitig•the.iis :ofthe.Fedetal Way CMmutiity Cpnter, 876 S. 336 ':Street. Federal Wad►, WashutgtorA:. Ven of space'is OW, TH�REFQRF,,'tlte Parties agree as follows':. . , . I. • on. Ili consideration ofrhe Ci aut}torizi ,ts u se. oi'the Federal Way: .. . CorYtmuiiity•Center, the Health. Piov'140 agr� to indemaify,arid, tiaid.the City; ~tts a ecic d u icials, . officers ; emplolrees, agents, Vt l unteers ,.sponsors,'contrributors slid from atxy donors it�tnle�ss '�td W l claims,'dettiatid$,losses , actionsand'liailities inclutiiy )' bj,yd ( ttg costs aid alI atlt fees 'to or all persons. •.or c hies, .including; wi oat ;limztataon; .,t}teir respective, agdnts; Iic=n0ees,. `or representadl es; atis ofirom, resulting4fromri,, or connected with :this 'Agreeiirtent or•the use;gf the Federal Wad CopitnU Center.or rolaiing;to the Fain — i4eattt & SafeiyNairto tli extent caused by the .nets 'eni irs.'or artiissior�s of� the Health'Ce::PM" ider; its. partners, slaareYiolch:rs,.a�;ents, . employs; ,�ni4ees or by t he tih •of This .�gre'ent, ?� ':' "The aIealt#i `+are.:1'roviider.aees. .•shit a :C'ertff cite .of.ce ' evidencing'toinmercial General Li ability in the amount of no.less Um $1;066,000 namit�g.t� pity. of Federal ay as additional insuirea,and Profession# Lialiity iiisttrarice lit. the :unourit'•of nb.less. than $l;t)OO;OOp:..The Certificate siYVrtld :be ptresented witt►'tlie. executed teEmeiat nc� late A'g �r;tl►an' Jart>Jacy 3 2614:. Fail to stiibtnitprOof of sack i ts�urapce.erid,cXe.cute thi; A letit shall pr+ohil t .the Heal-di`C -Ptd ideHront participating itt the F6de�al Wiy..r M , nttity •Ces ,&' Healt3. `' g (in ' Jan 18 `2014 3t' . !roviders who are 6aly l andt .'oiit informatiottal''brochures an not provid g'atty' ; screening, ittgnosis, or' medical' services do- not need to provide proof of insutnnce as regti red.Itt • sectton'.3' shove,: • , • . • • . nt ` ' Subs the ceriifieate 'of 'iris : mace, .if .t q :s :' •..,: : w iced, .turd .thc exeputed u" y Agreement rio later thari':Jarivary., 201 to: ; K Fite 1 ben..... t �1n I�►''h�1 01�, ess�lti'lhieta (.`Qi3tdlttatU[' Cif ► of Fei%rai wiy :76,,$,.,33:j St. :... :.:. .I? ayi.. , W.A 98{W3 .Neidth lair. fcet n i . " • .. : >... . fir, .. • .. , . .