17-101.01 Sargent Engineers: North Sullivan ITS 11101:01
VAWashington State
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Department of Transportation
Supplemental Agreement Organization and Address
Number 17-101.01 Sargent Engineers,Inc,
A Agreement Number 320 Ronlee Lane NW
Original 9 Olympia,WA 98502-9241
17-101
Phone: (360)867-9284
Project Number Execution Date Completion Date
Federal Aid#CM-4103(012) December 31,2020
Pro)ect Title New Maximum Amount Payable
North Sullivan ITS $5,992 00
Description of Work
Scope of Services to include.
I.Prepare Plans and details in ACAD to support conduit crossing on side of the Sullivan Road UP Railroad Bridge(Bridge No
4510) and the BNSF Railroad Bridge(Bridge No.4502).
2.Prepare project special provisions for conduit bridge crossing work in Microsoft Word
3. Design Services During Bidding and Construction,as needed.
The Local Agency of City of Spokane Valley
desires to supplement the agreement entered in to with Sargent Engineers,Inc
and executed on August 22,2017 and identified as Agreement No 17-101
All provisions in the basic agreement remain in effect except as expressly modified by this supplement.
The changes to the agreement are described as follows:
Section 1, SCOPE OF WORK, is hereby changed to read.
Added#3 to Scope of Services as follows.
3. Design Services During Bidding and Construction,as needed
II
Section IV, TIME FOR BEGINNING AND COMPLETION, is amended to change the number of calendar days
for completion of the work to read. New Completion Date is December 31,2020
Ill
Section V, PAYMENT shall be amended as follows:
N/A
as set forth in the attached Exhibit A, and by this reference made a part of this supplement.
If you concur with this supplement and agree to the changes as stated above, please sign in the Appropriate
spaces below and return to this office for final action
By, Erik Mara, Princi.al / By Mark Calhoun Ci Mana_ci
2i� Consultan ire 1'i C Approving Authority ignature
1211072SD M
Date
DOT Form 140-063
Revised 09/2005
ACO d CERTIFICATE OF LIABILITY INSURANCE DA�sMR'VD s"Y)
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(les)must have ADDITIONAL INSURED provisions or 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 tome. T Sarah Fish
Hall&Company PHONE FAX -
19660 10th Ave NE wyc xo Fm 380826-2961 (AIC,NP) 360-628-2981
Poulsbo WA 98370 ADDRESS sfish(E0hallandcompany.com
INSURER(S)AFFORDING COVERAGE NAIL#
INSURER A,US Specialty Insurance Company 29599
INSURED SAROENG-02 INSURER B The Travelers Indemnity Company 25658
Sargent Engineers Inc INSURER The Travelers Indemnity Company of America 25866
320 Ronlee Lane NW
Olympia WA 98502 IMs0RER0
INSURERE:
INSURER F.
COVERAGES CERTIFICATE NUMBER:1371004050 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 MUM'TypE OF POOL SUBMUM'EFF POLICY EXP
LTR 80 WVO POLICY NUMBER (MM/OD//WY) IMMIDWVYYI LIMITS
B X COMMERCIAL GENERAL UABILITY 6801N687340 2/21/2019 2/21/2020 EACH OCCURRENCE $2,000,000
CWM$-MADE X OCCUR DAMAGE TO RENTED
PREMISES(Ea occurrence) $1,000,000
MED EXP(Any one person) $10,000
PERSONAL 8ADV INJURY $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000
POLICY X JET LOC PRODUCTS-COMP/OP AGG $4,000,000
OTHER $
a AUTOMOBILE LIABILITY BA1 N689369 2/21/2019 2/21/2020 OMBINEEDi SINGLE LIMIT $1000,000
aocX ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY Far accident) $
AUTOSONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Pere Idem)
B X UMBRELLALMB X OCCUR CUP1N690903 2/21/2019 2/21/2020 EACH OCCURRENCE $2000,000
EXCESS LLB CWMS-MADE AGGREGATE $2,000,000
DED RETENTIONS $
C WORKERS COMPENSATION 6801N687340 2/21/2019 2/21/2020 PER
X ERx WA Slop Gap
AND EMPLOYERS'LIABILITY YIN
ANYPROPRIETOWPARTHERIEXEOUTNEN(A EL EACH ACCIDENT $1,000,000
FFICERMEMSEREXOLUDEDi
(Mandatory In NH) EL DISEASE-EA EMPLOYEE $1,000,000
If yea reaerate under
DEBORIPTWN OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000
A ProMnlantl LabCla,me Made USS1929942 0/18/2019 8/162020 Per Clam $2,000,000
Aggregate $2000,000
DESCRIPTION OP OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional RemarsSchedue,may be attached If mere apace is required)
Project North Sullivan ITS
Certificate Holder Is/are an Additional Insured on the Commercial General Liability and Auto Liability when required by written contract or agreement regarding
activities by or on behalf of the Named Insured.The Commercial General Liability Insurance is primary insurance and any other Insurance maintained by the
Additional Insured shall be excess only and non-contributing with this insurance.Awaiver of subrogation applies to the Commercial General Liability,Auto
Liability,Umbrella/Excess Liability and Workers Compensation/Employers Liability in favor of the Additional Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Spokane Valley ACCORDANCE WITH THE POLICY PROVISIONS.
10210 East Sprague Avenue
Spokane Valley WA 99206 AUT11oWg0 REPRESENTATIVE
LISA 4
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