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19-178.01 Commonstreet Consulting: Barker Rd Widening 19-178.01 mi Washington State P Department of Transportation Supplemental Agreement Organization and Address Number I Commonstreet Consulting,LLC. Original Agreement Number 100 S.King Street,Ste. 100 Seattle,WA 98104 19-178 Phone: 206-643-7238 Project Number Execution Date Completion Date 0275 November 19,2019 December 31,2022 Project Title New Maximum Amount Payable Barker Rd.Widening,Spokane River to Euclid Ave. $53,264.30 Description of Work Right-ofway services for the Barker Rd. Widening project between the Spokane River and Euclid Ave. The Local Agency of City of Spokane Valley desires to supplement the agreement entered in to with Commonstreet Consulting. LLC. and executed on 11/19/2019 and identified as Agreement No. 19-178 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: No change. I I Section IV, TIME FOR BEGINNING AND COMPLETION, is amended to change the number of calendar days for completion of the work to read: The completion date is revised to December 31,2022 III Section V, PAYMENT, shall be amended as follows: No change. 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. Mcr1K B : ! �rr'X' it( By: (afkui Consultant Signature Approving Authority Signature l`/ (9/ Dat1 DOT Form 140-063 `« Revised 09/2005 �-..No COMMCON-01 TMCKNIGHT ACORO• DATE(MM/DD/YYYY) �„,� CERTIFICATE OF LIABILITY INSURANCE 7/27/2021 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 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 NAME: CONTACT WAFD Insurance Group,Inc. PHOONro,Ext):(503)357-7111 FAX PO BOX 327 (A/C,No): 1909 Cedar St AI DRESS:tedm@wafdinsurance.com Forest Grove,OR 97116 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Liberty Mutual Insurance INSURED INSURER B:SAIF Commonstreet Consulting LLC INSURER C: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 WVD IMM/DD/YYYY) IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR BLS58159671 .r', 8/1/2021 8/1/2022 DAMAGETORENTED 1,000,000 X /rg¢; PREMISES(Ea occurrence) $ •' MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 r. GEM.AGGREGATE LIMIT APPLIESPEA., +Jrr. GENERAL AGGREGATE $ 2,000,000 X POLICY jj8T [ J LO PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: - I•- $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ A RTU EONpS ONLY SCHEDULED BODILY� INJURY(Per accident) $ A�TOS ONLY ___- AUUTO-0S ONLY (Peracoie DAMAGE $ $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESSLIAB CLAIMS-MADE ES058159671 8/1/2021 8/1/2022 AGGREGATE $ DED RETENTION$ $ 5,000,000 B WORKERS COMPENSATION X STATUTE _ ERH AND EMPLOYERS'LIABILITY Y/N , 100020541 1/1/2020 1/1/2021 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDEN# , $ OFFICER/MEMBER EXCLUDED? 1 N/A •� (Mandatory m NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Professional Liabili MPL20222282.20 7/28/2021 7/28/2022 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Professional Liability Aggregate Limit$2,000,000 City of Spokane Valley is an additional insured certificate holder to the extent of coverage provided under form CG8810 0413 Project: Agreement Number 19-178 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 L a:,- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMONSTREET CONSULTING LLC Page 1 of 2 STATE OF WASHINGTON Department of Labor & Industries Certificate of Workers' Compensation Coverage November 10, 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 3 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=... 11/10/2021 COMMONSTREET CONSULTING LLC Page 2 of 2 http s://secure.l ni.wa.go v/verify/Details/l i ab i l ity Certificate.aspx?UBI=604107152&LIC=... 11/10/2021