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20-085.01 Commonstreet Consulting: Sprague/Barker Intersection Ilik 171 Washington State 1I/ Department of Transportation Supplemental Agreement Organization and Address Number I Commonstrect Consulting,LLC. Original Agreement Number 100 S.King St.,Ste. 100 Seattle,WA 98104 20-085,C I Phone: Project Number Execution Date Completion Date 0205 04/29/2020 12/31/2023 Project Title New Maximum Amount Payable Sprague/Barker Intersection Improvement Project $68,567.25 Description of Work Right-of-way services for the 0205 Sprague/Barker Intersection improvement Project. The Local Agency of City of Spokane Valley _ desires to supplement the agreement entered in to with 2Qmmonstreet Consulting.LLC. and executed on 04/29/2020 and identified as Agreement No. 20-085 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: I Section 1, SCOPE OF WORK, is hereby changed to read: No changes. II Section IV, TIME FOR BEGINNING AND COMPLETION, is amended to change the number of calendar days for completion of the work to read: contract end date is revised to 12/31/2023. III Section V, PAYMENT, shall be amended as follows: 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: Mei'- ' 2,. J By: J vlt.v !-fu Hr,a.✓ A/-/A.._.____, Consultant Signature Approving Authority Signature 6 -- 2S--ZI Date DOT Form 140-063 Revised 09/2005 COMMONSTREET CONSULTING LLC Page 1 of 2 Oilr-s-)1) STASI OF WASHINGTON Department of Labor& Industries Certificate of Workers' Compensation Coverage June 21, 2021 WA UBI No. 604 107 152 L&I Account ID 652,018-00 Legal Business Name COMMONSTREET CONSULTING LLC Doing Business As COMMONSTREET CONSULTING Workers' Comp Premium Status: Account is current. Estimated Workers Reported Quarter 1 of Year 2021 "11 to 20 (See Description Below) Workers" Account Representative Employer Services Help Line, (360) 902-4817 Licensed Contractor? No What does "Estimated Workers Reported" mean? Estimated workers reported represents the number of full time position requiring at least 480 hours of work per calendar quarter. A single 480 hour position may be filled by one person, or several part time workers. Industrial Insurance Information Employers report and pay premiums each quarter based on hours of employee work already performed, and are liable for premiums found later to be due. Industrial insurance accounts have no policy periods, cancellation dates, limitations of coverage or waiver of subrogation (See RCW 51.12.050 and 51.16.190). https://secure.lni.wa.gov/verify/Details/liabilityCertificate.aspx?UBI=604107152&LIC=&... 6/21/2021 COMMONSTREET CONSULTING LLC Page 2 of 2 https://secure.lni.wa.gov/verify/Details/liabilityCertificate.aspx?UBI=604107152&LI C=&... 6/21/2021 __---.NN COMMCON-01 KANDREW A �R� CERTIFICATE OF LIABILITY INSURANCE DA7/28/2020 TE 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 N U ACT Kay Andrew WAFD Insurance Group,Inc. PHONE FAX PO BOX 327 (NC,No,E:t):(503)357-7111 (Arc,No): 1909 Cedar St ADDRESS:kay@IDpacificinspartners.com Forest Grove, OR 97116 INSURER(S)AFFORDING COVERAGE NAIL* INSURERA:Ohio Security Insurance Company 24082 INSURED INSURER B:SAIF Commonstreet Consulting LLC INSURERC:Hiscox Insurance Company 100 S King St Ste 100 INSURERD: Seattle,WA 98104 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD MIVD (MMIDDIYYYY) (MMIDDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X BLS58159671 8/1/2020 8/1/2021 PREMISESIEao rrence) $ 1;000,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ACT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: -_ $ COMBINED AUTOMOBILE LIABILITY (Ea accidentSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSO ONLY _AUTOS BODILY BODILY INJURY(Per accident) $ AUTOS ONLY _AUTOS ONLY (e08code-itliAMAGE $ $ A UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS MADE ES058159671 811l2020 8/1/2021 AGGREGATE $ 5,000,000 DED RETENTION$ OVER GL ONLY $ B AND EMPLOYERS'LIABILITY X I STATUTE I I ERA ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 100020541 1/1/2020 1/1/2021 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes.descnbe under 1000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ ' C Professional Llab MPL20222282.20 7/28/2020 7/28/2021 Each Claim 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers Compensation is for Oregon only employees. Project#20-085. City of Spokane Valley is an additional insured to the extent of coverage per form CG8810 0413. Professional Liability aggregate limit is $2,000,000. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Spokane ValleyTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 10210 E Sprague Ave Spokane,WA 99206 AUTHORIZED REPRESENTATIVE I 9‘57i14t) ! ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD