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AG 16-036RETURN TO: M1n EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: PUBLIC WORKS / S W IA 2. ORIGINATING STAFF PERSON: 140A \► e- , ► \ley 4. TYPE OF DOCUMENT (CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ) ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT EXT: S 1 3. DATE REQ. BY: 3 17—c () (,Q ❑ PROFESSIONAL SERVICE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT ❑ REAL ESTATE DOCUMENT ❑ ORDINANCE ❑ CONTRACT AMENDMENT (AG #): ❑ INTERLOCAL E OTHER S ro . V a.w►.< S 5 Or. c% "rv\pt.eannhI f i eza-ti 'n pl ree 'vtcyti-- ❑ MAINTENANCE AGREEMENT ❑ HUMAN SERVICES / CDBG ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS) ❑ RESOLUTION 5. PROJECT NAME: S (etc LEAS G �V PJT 6. NAME OF CONTRACTOR: N O Y441. 0141 vP < <- S 1Mb Vi C CAA ADDRESS: TELEPHONE:0(00 3? el - 8'OS 1 E -MAIL: ` r FAX: SIGNATURE NAME: I•1 W ��y Err cc G 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, EXP. 12/31/ UBI # , EXP. / / 8. TERM: COMMENCEMENT DATE: J 1 5-1 1(e COMPLETION DATE: Si 131 I (p 9. TOTAL COMPENSATION: $ /9' (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 XPROJECT MANAGER 1st DIVISION MANAGER ❑ DEPUTY DIRECTOR X.DIRECTOR fit. RISK MANAGEMENT (IF APPLICABLE) ILAW DEPT 11. COUNCIL APPROVAL (IF APPLICABLE) 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR INITIAL / DATE REVIEWED INITIAL / DATE APPROVED COMMITTEE APPROVAL DATE: DATE SENT: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS INITIAL / DATE SIGNED ❑ LAW DEPT ❑ CHIEF OF STAFF XSIGNATORY (MAYOR ❑ CITY CLERK ASSIGNED AG # X SIGNED COPY RETURNED TURN-ONE ORIGINAL AG# DATE SENT: 211 t10 No si. `'`'$ V-0349 SJ.2j /i(o COUNCIL APPROVAL DATE: DATE REC'D: COMMENTS: `, t L �^ EXECUTE � ORIGINALS SW VA. WOwq \ 1 -C. V YGWT� FIN " cOV Oyu' `� A�WI Ql/1 R.ae&S e Pvevkt r t t• w ∎Nk b c da \,Pere d us a.v► d k ►.ed SW M S F Po }{-cLet to cit. • As So vs lk r e.c_d a- coed t CA-.17s ce Gear%- -icake • 1/15 205 B West Patison Street Port Hadlock, WA 98339 360-379 -8051 www.nosc.org nerreca @nosc.org NOSC Hold Harmless and Indemnification Agreement 1 . C qQ. F'edev' i 1tsJc y assumes sole responsibility for the care and safety of FIN, the Migrating Salmon and of all persons engaged in the movement or towing of FIN during the period of time it is outside the control of the North Olympic Salmon Coalition (NOSC) and its employees and agents. 2. Qi i-9 of >r"eder t vicki agrees to comply with all relevant provisions of Title 46 RCW as well as any applicable provisions of local ordinances governing the operation of motor vehicles. 3. of—Feeley—al 1/J hereby releases NOSC, its Board of Directors, employees and agents from all liability or responsibility occurring as a result of C; ti..Sc 's use of FIN the Migrating Salmon. CIA-9 o f wed cv-63. Wo _ further agrees to indemnify and hold NOSC, its Board of Directors, employees and agents harmless with respect to any and all claims for damage to property or for injuries to persons resulting from the acts of n f- (= P17tWad. W' or its employees, agents or guests. C, }'ti of Ptckvai. wctAl further agrees to repair and feplace any NOSC property or equipment that may be damaged during, or as a result o f , C A I off- Fed eYcxt we 's use of NOSC property or equipment. 4. Prior to (! }' 1 o f e rat 1A c y 's use and movement of FIN, the Migrating Salmon,ri }-ti o F c'edcy-cd lt.ia,.1 is required to maintain liability insurance in force and good standing on the driver /vehicle towing the trailer, at a minimum liability insurance limits of $2,000,000 aggregate /$1,000000 per occurrence. i o 4 �,._ shall furnish a ce ' icate of insurance to NOSC, evidencing this coverage. Signat WA Title 46 RCW http: // apps. leg. wa.gov /rcw /default.aspx ?Cite =46 ;\2 \ Date N:\Administrative \FIN's Folder \FIN materials, info, templates, maintenance\Hold Harmless 2014,doc AC ® R° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/4/2016 THIS CERTIFICATE IS 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 SUBROGATION IS 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(s). PRODUCER Leavitt Group Northwest 2121 70th Ave West, #B University Place WA 98466 CONTACT Cathy Fleck NAME: y PHONE N . Ext): (253) 565 -3500 FAX No): (253) 565 -7209 E -MAIL cathy-fleck@leavitt.com ADDRESS: y INSURER(S) AFFORDING COVERAGE NAIC # INSURER A Argonaut Insurance Company 19801 INSURED City of Federal Way 33325 8th Ave S Tonia Proctor ARM Federal Way WA 98003 -6325 INSURER B National Casualty Company 11991 INSURER C : 12/31/2016 INSURER D : $ 10,000,000 INSURERE: $ INSURERF: COVERAGES CERTIFICATE NUMBER:CL161405284 REVISION NUMBER: 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADM INSD SUBR WVD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP IMM /DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 2902013 -01 12/31/2015 12/31/2016 EACH OCCURRENCE $ 10,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ CLAIMS -MADE X OCCUR MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 10,000,000 GENERAL AGGREGATE $ 10,000,000 GE X 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC PRODUCTS - COMP /OPAGG $ 10,000,000 Public Officials E &O $ 10,000,000 A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED N NON-OWNED AUTOS 2902013 -01 12/31/2015 12/31/2016 COMBINED SINGLE LIMIT (Ea accident) $ 10,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ x UMBRELLALIAB EXCESS LtAB OCCUR CLAIMS -MADE XC00000378 12/31/2015 12/31/2016 EACH OCCURRENCE $ 10,000,000 $ AGGREGATE $ DED RETENT ON $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N 1 A 2902013 -01 12/31/2015 12/31/2016 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A 2902013 -01 12/31/2015 12/31/2016 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Operations of the Named Insured CERTIFICATE HOLDER CANCELLATION Proof Of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE D DeLorenzo /CAFLEC Q,Ai 1Vv--'_ ACORD 25 (2014/01) INS025 omann © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,,N.