Loading...
AG 14-007RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIv: PROS / 2. ORIGINATING STAFF PERSON I VVV 65 i Z/) 511,4 ` \ EXT: - 3. DATE REQ. BY: 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 ❑ RESOLUTION ❑ CONTRACT AMENDMENT (AG #): ❑ INTERLOCAL 6'VTHER l�fll.LC� �ti,I✓ 5. PROJECT NAME: t" IVI.a�.0 i'Tjjan��A,Lta�i�.Ca�6� ea -l"ll 4- �� _ (� � ✓ r 6. NAME OF CONTRACTOR: , J : + _ _gym �'1 G 1 �e ►- 1 e i, �� 1 e ADDRESS: I S LD • 3 3) TELEPHONE: ��3 35 8"111 E -MAIL: y� FAX: �--F SIGNATURE NAME: � 5 C -VY-A �T�.S S i <i TITLE: 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 # BL. EX+P.�12 /31/ UBI # , EXP. 8. TERM: COMMENCEMENT DATE: - 1 j -T COMPLETION DATE: 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 �S PRO ECT MANAGER ❑ SUPERVISOR • DIRECTOR • RISK MANAGEMENT (IF APPLICABLE) • LAW DEPT 11. COUNCIL APPROVAL (IF APPLICABLE) INITIAL / DATE REVIEWED 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: vec� �►�su INITIAL / DATE SIGNED AG# DATE SENT: ul INITIAL / DATE APPROVED COUNCIL APPROVAL DATE: DATE REC'D: Lill 1/9 FROM :BALL CHIROPPRRCTIC CENTER FAX NO. :2536613610 Dec. 3e 2013 04:42PM P2/3 FEbFRAL WAY FAMILY HEALTH .& SAFFI vn� N _' 1<Alit . I t tcA`rlox AND lxsuxArrc� AGYREEMENT TWsindeiunil'icjt on -siad I i"catco'beslp�►v�r� IiSllfat7cL,%�g7C�'triC77i( "A� t' �9 1t+ed :J t�l t�C.S Th p .4f vr VI61s�'date i�Vay, .. a 'Was .. psri es ("Panics") to this !'agreement are. 'City f Federal muticipai corporatiop ( "Ci F� >'' • �"Ht vsdtr"�; .. tY ? . 'k-,71W H s th� jCare: Pro Wei. wishes to .eo�bit ` c' ::' ' : ' • . . Health `Feir :setvi cs fort Federal v4 ' to ng. se.of, *C F sec $76 S: ti�`'Str� PedbrW Way; V1tas the tr Federal C:ommttnit�r , 1 . bt4a Venda�r spaces is SSQ. hid; T�iERF.Ft,R,'i as fgltors: a _ 1; �iaat oftlie'Ci a its Comrnii ty miter .tie 1:I ''; citttori— ^use. Q�''the F'ede$at'Wa P-i,a y , 8 s °' krtciern ;fy a hold ; jits:Oected, ": teers•ponsors , ticttii sue: all d s ,:losses =:AC$p aQd liihiiines ( d aN ktacml�s to afly odd all <:.ar_.enti�iet, JW Odin g; it tout �3m ey.fee to or yapyw �tv 'their 'spec =tiv� mitts:. " S. m, re$tdt wah :t1di Lam', or Fcderai'ii -C�i Cter:ot rel: .the -Family Aern; or ".tLc: useif,tLe ,or.ciIth ei: uoe..e�cacnt.ca»d *. cif tfie` H Care Pr ;i ick its, etplopees;:ies ot'bYthd`ich:tif This r•' ;pattters, .sldY.rs, agents, ekanei�t:.: r. Vaal a Pir,�►i+deii�.aecs'io. $ati mot': of N:y�t Ge°4ai iiabihtyin2he aztot gfrtri less.i,pQp, SI Q00;QpO:..Tb �;ertiftee sho(M be io• �iiunz�f�o less: J YI. 1014-Ti 9tire P r+t d vvittt :'they xxecutcd to t,nc,: . the Heal Te; i s �t Hof sac :i suraoee:a exe.c%g t s gce iet�t shallprt?hi ,it ilia gartrcipalrivag in.I�.: F 3'3raacoity:C�eiat lea a,.' ..:.. :Pro :vit%rswbo Are Y �g-out:ia�fo - `•• • "-' ,`:. ' •' .• ... acre r ioiia brochures and— `= sctYiees da ratY. s�ciign?: ..... `ts, piaeie prari {(at itistc� es 1416, � . . il' egiced,.ni3. the e} • ' x. F• .. .. , .z9Atlti .t. , . . 1►F W 1O . �Y" 4$:00 .. • - , .. JC 16 .1 �i�ia, FROM :BALL CHIROPPRACTIC CENTER FAX NO. :2536613610 Dec. 30 2013 04:43PM P3/3 CITE' 4F FEDERAL WAY A'I"i'FST ' _ area MoNcilly, CMC, C' Cie ; .. : . Date' HIEALTH CAE PROVIDER, Is (P'rizt%d•Now mg Title) (Orgavintian:I?aae) � P • � � (AMYL VVV� .. • y1 � � � ...• �•� 1 'd` . Dater �. l.. :�!• �:p ��,`..,.„_.......� • � �� �. • �•. • �� �� •� • •.� • .:. '� • •• STATE (1F':iA5HIl�1tafTbl` • ., f' - :. ;' x ' CfltIN?'.OF E}nahs :day :poils>1 appcd beforlr' �C�!bU�. l xai; # tea bae w C hP.: of ttiat: eiceau►ted e j . 'a d clm..a3 njo aal.a&iM f :rstir ' be:thei ryd deei# ofsaid Garpo atiori; €u ' ie•nges act pittpose s e �iai'i a ed, and oti oath sta a! VYSB a a J � and thpi tale'aEo•..� at�a C COT fOPa Cr9Ca� O , w� 'ski C11 �fld : � day. f. � .. . nwbe tNe of Writhi7., sg I, gl'It.OM$0r AppoiMaNnt Expire PubZiC.ltl �nd'fi� tip ofd•• 'MY WIM1.11=n Heal Fa i8cation' ` •. ari-.813 . •