Loading...
AG 17-069RETURN TO: PW ADMIN EXT: 2700 ID# CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: PUBLIC WORKS /�SLc )m ^ 2. ORIGINATING STAFF PERSON: I I/ L i {CI E Fn a l (S 4. TYPE OF DOCUMENT (CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ) ❑ PUBLIC WORKS CONTRACT ❑ ❑ PROFESSIONAL SERVICE AGREEMENT ❑ ❑ GOODS AND SERVICE AGREEMENT ❑ REAL ESTATE DOCUMENT ❑ ❑ ORDINANCE ❑ ❑ CONTRA'Cj� AM N�TIqMENT (AG #): o ERRLLPpCAL %OTHERTTOVti4.rrnI €Ct v1�1 lndevini ra�L-hO1 5. PROJECT NAMEL5 t) n &Leif o Eve-pi & n � 1 NAME OF CONTRACTOR: MOV+G, Ol c trn,oiC . < s4l �'h 0� 01).4_14 � Qv) TELEPHONE:(c 3 /D(I) �� 7 q — ROS FAX: TITLE: EXT: 21 S(v 3. DATE REQ. BY: SMALL OR LIMITED PUBLIC WORKS CONTRACT MAINTENANCE AGREEMENT HUMAN SERVICES / CDBG SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS) RESOLUTION ADDRESS: E -MAIL: . SIGNATURE NAME: N{'Ilcg EYI'LFLG 7. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS /CERTIFICATE REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT /AMENDMENTS CFW LICENSE # BL, EXP. 12/31/_ UBI # 6)18117. , EXP. /_ /_ 8. TERM: COMMENCEMENT DATE: 5/ q 11 COMPLETION DATE: 9. TOTAL COMPENSATION: $ 1 1 t DO (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 RETAINAGE: RETAINAGE AMOUNT: ❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDED ❑ PURCHASING: PLEASE CHARGE TO: 140 ^ 3 o-D _ 430 - 5L Z - (IT- 312_ ❑ ALL OTHER 10. DOCUMENT / CONTRACT REVIEW PROJECT MANAGER XDIVISION MANAGER +DEPUTY DIRECTOR L 4DIRECTOR )4" RISK MANAGEMENT (IF APPLICABLE) XLAW DEPT INITIAL / DATE REVIEWED INITIAL / DATE APPROVED 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 o CREATE ELECTRONIC REMINDER/NOTIFICATION FOR 1 MONTH PRIOR TO EXPIRATION DATE (INCLUDE DEPT. SUPPORT STAFF IF NECESSARY AND FEEL FREE TO SET NOTIFICATION MORE THAN A MONTH IN ADVANCE IF COUNCIL APPROVAL IS NEEDED.) ❑ LAW DEPT }SIGNATORY (MAYOR O IRECTOR ❑ CITY CLERK Ar ASSIGNED AG # X SIGNED COPY RETURNED RETURN ONE ORIGINAL COMMENTS: EXECUTE °,Z° ORIGINALS •tA1rn would Lie INITIAL / DATE SIGNED 141 'NO(A rtva AG# -Olen DATE SENT: 0A'20 1 } 'to Kait "FIN" -ftsr o cSa Lrna -rL I-t L1 L SL 3/2017 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. e i 1 pt pet, l tAiltul assumes sole responsibility for the care and safety of FIN, the Migration 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. CI Ill 0 f it'dei'di Wa agrees to comply with all relevant provisions of Title 46 RCW as well as ail), applicable provision of local ordinances governing the operation of motor vehicles. 3. M 0 FCd e'i i hereby releases NOSC, its Board of Directors, employees and agents Mg all liability or responsibility occurring as a result of c d ' ' h: se of FIN the Migrating Salmon. �' ( 04 Federal (I ) further agr - s to indemnify and old NOSC, its Board of Directors, ployees and agents ha less with respect to any and all claims for dam . ge to .ro erty or for injuries to persons resulting from the acts of 1 Fe ( or its employees, agents or guests. C%,4 , o1 Fe dint' Irii ry furtheagrees to re� a•i'r and r- lace any NOSC property or equipment theft may be damaged duripit, or as a result of, C.i i`j 04' PA LMA lAktA_j 's use of NOSC property or equipment. 4 prior to driver /vehicle towin 's use and movement of FIN, the Migrating Salmon, fired to maintain liability insurance in force and good standing he traile at a minimum liability insurance limits of $2,000,000 egate /$1,000000 per occurrence. G(,t' Of I(, t fArL/ tAkij shall furnish a certificate of ce to NOSC, evi• - ncing this coverge. r1 L[11,2..a1-1 Signatur= Date Company /Organization authorized person Printed name WA Title 46 RCW http: // apps .leg.wa.gov /rcw /default.aspx ?Cite =46 N:Wdministrative \FIN's Folder\FIN materials, info, templates, maintenance\Hold Harmless 2015.doc ® ACp0 CERTIFICATE OF LIABILITY INSURANCE `v DATE(MM /DB/YYYY) 1/9/2017 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 1S 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 ttH y (253) 565 -3500 ( . (253)565 -7209 Ao .cathy- fleck @leavitt.com INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A:Argonaut Insurance Company COMMERCIAL GENERAL LIABILITY 19801 C18058 INSURED City of Federal Way 33325 8th Ave S Ionia Proctor ARM Federal Way WA 98003 -6325 INSURER a :Philadelphia Insurance Company INSURERCNational Casualty Company 11991 INSURERD:TraVelers Casualty & Surety Company 19038 INSURER E; 1 CLAIMS -MADE I X I OCCUR INSURERF: $ COVERAGES CERTIFICATE NUMBER:CL171912041 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. 'KW LTR TYPE OF INSURANCE 7fObL INSD SUBR NND POLICY NUMBER POLICY EFF IMMIOD/YYYYI POLICY P LIMITS A X COMMERCIAL GENERAL LIABILITY 2902013 -02 12/31/2016 12/31/2017 EACH OCCURRENCE $ 10, 000, 000 1 CLAIMS -MADE I X I OCCUR TO RENTED PRREMISES (Ea occurrence) $ MED EXP (Any one person) $ Excluded PERSONAL& ADV INJURY $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 X POLICY l I 7a (. I LOC OTHER: PRODUCTS - COMP/OP AGG $ 10, 000, 000 Public Officials EBO $ 10,000,000 B AUTOMOBILE LIABIUTY P8PK1588960 1/1/2017 1/1/2018 COIASINED 0 SINGLE LIMIT $ 10,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS HIRED AUTOS II SCHEDULED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE aa (Per idenU $ E C - ){ UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE XC00000689 12/31/2016 12/31/2017 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ OED 1 1 RETENT ON$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER /EXECUTIVE OFFICER/MEMBER or EXCLUDED? I INIA (Mandatory in NH) 0_ m describe under DESCRIPTION OF OPERATIONS below 2902013 -02 12/31/2016 12/31/2017 I STATUTE I I ER E.L. EACH ACCIDENT $ 1,000,000 E.L DISEASE - EA EMPLOYEE $ 1,000,000 E.L DISEASE - POLICY LIMIT $ 1,000.000 D Crime Coverage /Cyber 105862866 1/1/2017 1/1/2018 Crime 1,000,000 Cyber 1,000,000 DESCRIPTION OF OPERATIONS 1 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 ACORD 25 (2014/01) 1NS025/?m4ml ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD