Loading...
AG 15-029 RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: PRCS/ 1 f L_ 2. ORIGINATING STAFF PERSON: K1(V\ A J S V�e-1, Y1 EXT: el 3 2. 3. DATE REQ.BY: 1/i / L j 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 AM NDMENT AG#):. ❑ INTERLOC L r'' X OTHER I i�)AMENDMENT i 1 1 Mk/6Y\ b r m c vvt 11.9 ~�'� 4 Sc�1��( ra.1 r 5. PROJECT NAME: �{ ) A k c �.-1 tr, S�j J4 u r 6. NAME OF CONTRACTOR: 1 -i*Vi ,;k v +—\ \l L l ic) L l5 C 1 ADDRESS: el(o 1•Je4, ) j 5 s i bite-fi w A Ci's--v-2-7 TELEPHONE: f{2j'36'/- 3-°O E-MAIL: ` FAX: SIGNATURE NAME: (. .o et( TITLE I yr 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# 1 EXP. 12/31/ UBI# ,/EXP. / / 8. TERM: COMMENCEMENT DATE: )/ 1 I I 4-> COMPLETION DATE: I ! C - 9. TOTAL COMPENSATION:$ 0 (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. DOCUMENT/CONTRACT REVIEW INITIAL/DATE VIEWED INITIAL/DATE APPROVED ,'PROJECT MANAGER ,05 1'7- 3i 114 ❑ SUPERVISOR ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) lLAW DEPT s'//f 11. COUNCIL APPROVAL(IF APPLICABLE) COMMITTEE APPROVAL DATE: COUNCIL APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY,INSURANCE CERTIFICATE,LICENSES,EXHIBITS INITIAL/DATE SIGNED ❑ LAW DEPT * � .��ZIM SIGNATORY(MAYOR OR DIRECTOR) �._ CITY CLERK 1 /4/WNW ASSIGNED AG# `6(SIGNED COPY RETURNED DATE SENT: \ ❑RETURN ONE ORIGINAL COMMENTS: t egIVIA KaS ■va■Uec1 tv1SUr tAce nuireimafth efThr ve✓l - w ko ot,I e V �Pm n 1 n-f gym., (I, ird . J 11/9 FEDERAL WAY FAMILY HEALTH & SAFETY FAIR INDEMNIFICATION AND INSURANCE AGREEMENT This Indemnification and Insurance Agreement ("Agreement") is dated effective the later date indicated below with the signature. The parties ("Parties") to this Agreement are the City of Federal Way, a Washington municipal corporation("City") and King County Rural Library District("KCLS"). A. KCLS wishes to contribute services for the Federal Way Family Health & Safety Fair on January 17, 2015; and B. The City wishes to cooperate by allowing the use of the Federal Way Community Center, 876 S. 336th Street, Federal Way,Washington. Vendor space is $50. NOW, THEREFORE, the Parties agree as follows: 1. Indemnification. In consideration of the City authorizing its use of the Federal Way Community Center, KCLS agrees to release and hold the City,their directors,officers,agents,representatives,employees and volunteers ("Released Parties") harmless from and against any and all claims, actions, damages, liability of every type and nature, including all costs and legal expenses incurred by KCLS or the Organizing Entity, by reason of KCLS's activities arising under or in connection with its participation in the above-named event, including loss of life, personal injury and/or damage to property,except as may result or be caused by the acts of the Released Parties,or any of them individually. 2. Insurance. KCLS agrees to submit a Certificate of Insurance evidencing Commercial General Liability in the amount of no less than $1,000,000 naming the City of Federal Way as additional insured and Professional Liability insurance in the amount of no less than$1,000,000. The Certificate should be presented with the executed Agreement no later than January 2, 2015. Failure to submit proof of such insurance and execute this Agreement shall prohibit the KCLS from participating in the Family Health& Safety Fair on January 17, 2015. 3. Providers who are only handing out informational brochures and not providing any screening, diagnosis, or medical services do not need to provide proof of insurance as required in section 2 above. 4. City Contact. Submit the certificate of insurance, if required, and the executed Agreement no later than January 2, 2015 to: Kimberly Shelton, Fitness/Athletic Coordinator City of Federal Way 876 S. 333rd St. Federal Way, WA 98003 CITY OF FEDERAL WAY ATTEST Health Fair Indemnification 10/2013 1 4 ,. . At f/i .! )1_ -10 2.A Jim Ferrell, Ma + & -X • , CMC, City Jerk tihT".- 0.0nt4w3„ Date: �' HEAL CARE PROVIDER/VENDOR // (Signature) Ill odkin i f 1�Ltlw ' i, S4'vwi, (�. ins (Prim-d Name an. Title) • Wu 1 (Organi .tion N. -) 1Do NQw 4 WI IOW, tsc vih W11 'nor' (Address) 425- 3it2q - 32OD (Phone) ll Date: (n I % I STATE OF WASHINGTON ) ) ss. COUNTY OF V-10(1 ) On this day personally appeared before me i-tOLL -bet L.UJ(n , to me known to be the 171 tz D2 (9 -RA FLICSW, of V-{►J 6 0,0t&.tJn L\- k -y 5\ ct M that executed the foregoing instrument,and acknowledged the said instrument to be the free and voluntary act and deed of said corporation,for I the uses and purposes therein mentioned, and on oath stated that he/she was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. GIVEN my hand and official seal this 21 s-F- day of NO r✓ ;VIZ- , 201.. Not signature o�o��a Notary's � ��► � p R PUt;,. Notary's printed name o t F 61Z v../ I S.e/MA� ,.. 0,,..........°84 Notary Public in and for the State of Washington. �'f ' 0 V.t. My commission expires k2''Z-1 -2a I tv I '1;$$Pi ei�� ∎��• Health Fair Indemnification 10/2013 —2- I • 1' '