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22-139.01CommonstreetConsultingPinesBNSFGSP Washington State Department of Transportation Supplemental Agreement Organization and Address Number 1 Commonstreet Consulting,LLC. 92 Lenora St.,PMB 125 Original Agreement Number Seattle,WA 98121 22-139 Phone: Project Number Execution Date Completion Date 0223 8/15/22 12/31/24 Project Title New Maximum Amount Payable Pines Road/BNSF Railroad Grade Separation $256,251.03 Description of Work Right-of-way services for the Pines Rd./BNSF Railroad Grade Separation Project. The Local Agency of City of Spokane Valley desires to supplement the agreement entered in to with Commonstreet Consulting, LLC. and executed on 08/15/22 and identified as Agreement No. 22-139 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: -Seetien-1-, SCOPE OF WORK, is hereby changed to read: N/A Section IV, TIME FOR BEGINNING AND COMPLETION, is amended to change the number of calendar days for completion of the work to read: 12/31/25 --S-ectiori-V, PAYMENT,shall be amended as follows: N/A he-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: Chris LaBonte By: T© ,-, �w ate(Dec 1!2024111:PST ��" Consultant Signature Approving Authority Signature / . - 23- 2— Date DOT Form 140-063 Revised 09/2005 Exhibit "A" Summary of Payments Basic Supplement#1 Total Agreement Direct Salary Cost Overhead (Including Payroll Additives) Direct Non-Salary Costs Fixed Fee Total DOT Form 140-063 Revised 09/2005 A`�d CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/21/2024 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 CONTACT Shelley Pace NAME: Huggins Insurance Services,Inc. (A/C, EM); (503)585-2211 FAX No): (503)399-4658 P.O.Box 270 E-MAIL shelley@huggins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# Salem OR 97308 INSURERA: Hartford Underwriters 30104 INSURED INSURER B: Saif Corporation 36196 Commonstreet Consulting,LLC INSURER C: Hiscox Insurance Co Inc 10200 92 Lenora St INSURER D: INSURER E: Seattle WA 98121-2108 INSURER F: COVERAGES CERTIFICATE NUMBER: 24/25 USE THIS ONE 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,DAMAGE TO RENTED 000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) nce) $ 1,000,000 MED EXP(Any one person) $ 10,000 A X Washington Stop Gap Y Y 52SBAAW7B5G 03/10/2024 03/10/2025 PERSONAL8ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 4,000,000 POLICY X PRO LOC PRODUCTS-COMP/OPAGG $ 4,000,000 JECT OTHER: WA Stop Gap $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 2,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED Y Y 52SBAAW7B5G 03/10/2024 03/10/2025 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LIAB CLAIMS-MADE 52SBAAW7B5G 03/10/2024 03/10/2025 AGGREGATE $ 4,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY Y/N 1000 000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N/A Y 100020541 01/01/2024 01/01/2025 E.L.EACH ACCIDENT $ , , OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , Each Claim $2,000,000 Professional Liability/Claims Made C Retroactive Date: 07/28/2017 MPL533800224 07/28/2024 07/28/2025 Aggregate for all Claims $2,000,000 Retention $5,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Agreement Number:22-139. Right of way services for the Pines Rd/BNSF Railroad Grade Separation Project. City of Spokane Valley is included as additional insured as respects to general liability and auto liability as required by written contract or agreement per form SL 30 32 06 21 attached. Primary and noncontributory,and waiver of subrogation applies as required by written contract or agreement per BUSINESS LIABILITY COVERAGE Form SL 00 00 10 18,and HIRED&NON-OWNED AUTO Form SL 02 30 10 18. 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 E Sprague Ave AUTHORIZED REPRESENTATIVE "/�` Spokane WA 99206 .% au - ej'„,�eCe— . 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD