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AG 14-013RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIv: PROS / 2. ORIGINATING STAFF PERSON: Kl lw ),, y? C V rI4 \, e hy) EXT: �C 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 A�MENDMENT(AG #): 1:1 INTEIRLOCAL THER 4- e-0j+Gk I ( GIQI i�1 Yl t �1 C�i`Il ttyi ✓✓i 5. PROJECT NAME: Fi�tynx uA r7�' C' S - T:i�a (✓- 6. NAME OF CONTRACTOR: jGt ADDRESS: TELEPHONE: E -MAIL: FAX: SIGNATURE NAME: TITLE: ln9=1f: 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, EXP. /31/_ UBI # , EXP. 8. TERM: COMMENCEMENT DATE: ,1I2 l a - `'f COMPLETION DATE: I - L4 9. TOTAL COMPENSATION: $ �jO (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 1:3 IF YES, $ PAID BY. C] CONTRACTOR ❑ CITY ❑ PURCHASING: PLEASE CHARGE TO: A ��N�O �A =a UL 10. DOCUMMPT / CONTRACT REVIEW k"PROJECT MANAGER ❑ SUPERVISOR DIRECTOR • RISK MANAGEMENT (IF APPLICABLE) • LAW DEPT 11. COUNCIL APPROVAL (IF APPLICABLE) 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: INITIAL/ DATE SIGNED AG# DATE SENT: ,I ' H ' INITIAL / DATE APPROVED COUNCIL APPROVAL DATE: DATE REC'D: 11/9 Jan 14 Z014 12:24:81 EST FROM: FZM/77603507659 MSG# 95577429 -006 -1 PAGE 664 OF 004 CERTIFICATE OF LIABILITY INSURANCE 1/14/2 14' THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A Statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(&). NORTHEAST AGENCIES INC /PHS 214608 P: (866) 467 -8730 F: (888) 44:3 -6112 NAME: (�No,EU): (666) 467 -8730 (Alc,No): (888) 443 -6112 AADDRLESB 301 WOODS PARK DRIVE INSURER(S) AFFORDING COVERAGE NAICt CLINTON NY 13323 INSURER A: sentinel Ins Co LTD IIM3URIM INSURER B: 01/0'1/2015 DCPS CORPORATION DBA: BALL INSURERC: PREMISES O R oew s) CHIROPRACTIC CENTER INSURER D: 1717 S 324TH ST STE B INSURER E: FEDERAL WAY 14A 96003 INSURER F; S2, 000, O C O THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUS IONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LNSR TYPE OP IM11RANL'E ADOL S118R POLICY.NU.118ER PDUCYEPP PDLICYEXP !AI/!TS A COMMEROm GENERAL LIAen rry CLAIMS-MADE W OCCUR X General Liab GEN'L AGGREGATE LIMIT APPLIES PER PgLICY E:1 ECT LOC OTHER: 01 SBA AW632'1 01/0'//2014 01/0'1/2015 EACH OCCURRENCE x 2, 000, 0 0 0 PREMISES O R oew s) -1,000, v C 0 X MEDEXP(AnymeDereon) 010,000 PERSONAL L ADV INJURY S2, 000, O C O GENERAL AGGREGATE a 4,000, 000 PRODUCTS • COMP/OP AGO AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON-OWNED AUTOS COMBINED SINGLE LIAR (En sawdenD DOWLY INJURY (Per parson) BODILY INJURY (Per eoddent) 10 PROPERTYDAMAGE (Per w4dent) e e UMBRELLA LIAR EXCESS LIAB 20CCUR CLAIMS.MADE EACH OCCURRENCE u AGGREGATE OEd RETENTIONS e.. 0DR11dW Lt WMASATWJN ANDGMPlDWN—LIANUTY ANY PROPRIETORIPARTNER/EXECLMVE YIN OFFIO MEMMA EXCLUDED? ❑ (Menolary ID NH) If Ye& de6Cdbe Under DESCRIPTION OF OPERATIONS below WA PER STATUTE ER EL6ACNACC(06NT u EL DISEASE- EA EMPLOYEE EL DISEASE• POLICY LIMB e l wle, maTwa wrffl limRe Mace lermaw reel Those usual to the Insured's Operations. Certificate Holder is an Additional Insured per the Business Liability Coverage Form SS0008 attached to this policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, The City of Federal Way AUTHORIZEDREPREBENTAT" $76 5 333Rb ST FEDERAL WAY, WA 98003 0 19882014 ACORD CORPORATION. All rights reservec ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD