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HomeMy WebLinkAboutPW Chng Ordrs 1and2 Thorndyke Road Culvert Replace Nordland Construction NWDepartment of Public Works O Consent Agenda Page 1 of 1 Jefferson County Board of Commissioners Agenda Request To: Board of Commissioners Mark McCauley, County Administrator From: Monte Reinders, P.E., Public Works Director/County Engineer Agenda Date: May 15, 2023 Subject: Change Order No. 1 and Change Order No. 2 with Nordland Construction NW, Inc., Thorndyke Road MP 4.71 Culvert Replacement, County Project No. 18020580, County Road No. 418708, RCO Project No. 20-1657R Statement of Issue: Change Order No. 1 and Change Order No. 2 with Nordland Construction NW of Nordland. Washington. Analysis/Strategic Goals/Pro's Et Con's: Change Order No. 1 replaces the specification for liquidated damages with a newer, more widely accepted specification and calculation method for liquidated damages. Change Order No. 2 is the final change order for the project and includes revising the unit bid price for the bid item Gravel Borrow, and also adding the bid item Topsoil Type B, as well as adding three working days for the placement of the topsoil. Change Order No. 2 also includes a final reconciliation of the contract amount to reflect actual bid item quantities used on the project, represented by adjustments for underruns and overruns on various bid item quantities. Fiscal Impact/Cost Benefit Analysis: There is no change to the contract amount for Change Order No. 1. Change Order No. 2 will decrease the contract amount by $17,761.56, from $1,749,021.00 to $1,731,259.44. The project is funded at 87% by the Washington Recreation and Conservation Office (RCO), with the remaining 13% funded by a National Fish Passage Program grant and the County Road fund. Recommendation: Public Works recommends that the Board authorize Change Order No. 1 and Change Order No. 2 with Nordland Construction NW, and return two originals to Public Works. Department Contact: Mark Thurston, P.E., Project Manager, 385-9160. Revie By: Mark McCain UY County Administrator Date 1 of 1 JEFFERSON COUNTY DEPARTMENT OF PUBLIC WORKS 1 11/10/2022 Ordered by County Engineer under terms of QSevtion 1 - 04.4 of the Standard Specifications Change proposed by Contractor Endorsed by: at re _ Title Consent given by Surety. By: ContractorFbm Name // required) Attomev--0-Fact Date CHANGE ORDER (Order No. Contract No. 18020580 To: Nordland Construction NW 6C1l- 123 Ponderosa Place diand, WA 98358 Project Title Thomdyke Road MP 4.71 Culvert Replacement You are ordered to perform the following described work upon receipt of an approved copy of this change order. This change order will make the following changes to the contract: 1) Replace Section 1-08.9 in the Special Provisions with the following: 1-08.9 Liquidated Damages (March 3, 2021 APWA GSP, Option A) Replace Section 1-08.9 with the following: Time is of the essence of the Contract. Delays inconvenience the traveling public, obstruct traffic, interfere with and delay commerce, and increase risk to Highway users. Delays also cost tax payers undue sums of money, adding time needed for administration, engineering, inspection, and supervision. Accordingly, the Contractor agrees: 1 _ To pay liquidated damages in the amount of — $200.00 � for each working day beyond the number of working days established for Physical Completion, and 2. To authorize the Engineer to deduct these liquidated damages from any money due or coming due to the Contractor. When the Contract Work has progressed to Substantial Completion as defined in the Contract, the Engineer may determine the Contract Work is Substantially Complete. The Engineer will notify the Contractor in writing of the Substantial Completion Date. For overruns in Contract time occurring after the date so established, liquidated damages identified above will not apply. For overruns in Contract time occurring after the Substantial Completion Date, liquidated damages shall be assessed on the basis of direct engineering and related costs assignable to the project until the actual Physical Completion Date of all the Contract Work. The Contractor shall complete the remaining Work as promptly as possible. Upon request by the Project Engineer, the Contractor shall furnish a written schedule for completing the physical Work on the Contract. Liquidated damages will not be assessed for any days for which an extension of time is granted. No deduction or payment of liquidated damages will, in any degree, release the Contractor from further obligations and liabilities to complete the entire Contract. The liquidated damages amount is based on the attached "Design Liquidated Damages Calculation Sheet'. All work materials and measurement to be in accordance with the provisions of the standard specifications and special provisions for the type of construction involved. ORIGINAL CURRENT ESTIMATED ESTIMATED CONTRACT I CONTRACT NET CHANGE CONTRACT TOTAL AMOUNT AMOUNT THIS ORDER AVER CHANGE $1,749,021.00 $1,749.021.00 $0.00 $1,749,021.00 ORIGINAL CONTRACT CURRENT CONTRACT CONTRACTTIME NEW CONTRACT TIME (days) TIME (days) CHANGE (AddlDel) TIME (days) 100 100 0 APPROVAL RECOMMENDED AP P AL RECOMMENDED 5 2 -7-2- Project Maqagef Date County Engineer APPROV COMMENDED APPROVED Engineering Services Manager Date Chair, Jefferson County Commissioners Date Sheet 1 of 1 Date: 12/12/2022 Ordered by County Engineer under terms of FK section 1 - 04.4 of the Standard Specifications Change proposed by Contractor Endorsed by� Nordland Construction NW —7i wc� ( Contractor Fim? Name nature Date (when By: Date JEFFERSON COUNTY DEPARTMENT OF PUBLIC WORKS Change CHANGE ORDER Order No. Contract No. 18020580 To: Nordland Construction NW 123 Ponderosa Place Nordland, WA 98358 Project Title Thomdyke Road MP 4.71 Culvert Replacement You are ordered to perform the following described work upon receipt of an approved copy of this change order. This change order will make the following changes to the contract: 1) Revise the unit bid price for Bid Item No. 5, Gravel Borrow Incl. Haul, from $32.00/ton to $26.00/ton. This i reduction in price is being made because the contractor is re -using gravel borrow material from the site, which was generated during site excavation, and that the contractor salvaged and stockpiled off -site. Therefore, the contractor does not have to purchase the material from a commercial supplier, and that cost is being subtracted from the unit bid price. This unit bid price will be for remaining quantity to be paid, and will not be retroactive to previously paid quantities. The total change in contract amount is (97.32 tons) X ($32/ton - $26/ton) = $583.92 2) Add the bid item 'Topsoil Type B" in accordance with Section 8-02 of the WSDOT Standard Specifications. Section 8-02.4 is revised with the following: Topsoil will be measured by the cubic yard in the hauling vehicle. Section 8-02.5 is revised with the following: "Topsoil Type B", per cubic yard. The unit bid price for Topsoil Type B shall be $50.00/cubic yard. The quantity of Topsoil Type B is 456 cubic yards, and therefore the total amount is ($50.00/cy) X (456 cy) = $22.800.00 Three days will be added to the contract time to complete this work. 3) Adjust the contract amount to reflect actual bid item quantities used on the project, as shown on the attached Final Pay Estimate. The total adjustment amount is a deduction of $39,977.64. This amount accounts for underruns and overruns on bid item quantities. The total change in the contract amount for this change order is (-$583.92) + $22,800 + (-$39,977.64) =-$17,761.56 The total increase in contract time is 3 days. All work materials and measurement to be in accordance with the provisions of the standard specifications and special provisions for the type of construction involved. ORIGINAL CURRENT ESTIMATED ` ESTIMATED CONTCAMOUNTT To CAOMOUANTT f ITH SCORDER ETHANGECAOFTER CHANGEL $1,749,021,00 '✓ ORIGINAL CONTRACT TIME (days) 100 $1,749,021.00 CURRENT CONTRACT TIME (days) 100 APPROVAL RECOMMENDED Project �7- Date Date 2 -$17,761.56 $1,731,259.44 CONTRACT TIME NEW CONTRACT CHANGE (Add/Del) TIME (days) 3 103 APP7�!E:commr:NDED County F Date APPROVED 0 Chair, Jefferson County Commissioners Date CONTRACT JEFFERSON COUNTY, WASHINGTON THIS AGREEMENT, made and entered into this / / day of _ l� , 20 2Z , between the COUNTY OF JEFFERSON, acting through the Jefferson County Commissioners and the Director of Public Works under and by virtue of Title 36, R.C.W, as amended and Nordland Construction NW of Nordland, Washington hereinafter called the Contractor. WITNESSF.TH: That in consideration of the terms and conditions contained herein and attached and made a part of this agreement, the parties hereto covenant and agree as follows: The Contractor agrees to furnish all labor and equipment and do certain work, to -wit: That the Contractor herein will undertake and complete the following described work: This Contract provides for the improvement of Thomdyke Road near milepost 4.71 by replacing the existing culverts with a new buried bridge, installation and removal of a temporary bypass road, structural earth walls, stream restoration, paving, guardrail, and other work for the total sum of One million seven hundred forty nine thousand, twenty one dollars (S 1,749,021.00 ) in accordance with and as described in the attached plans and specifications and the Standard Specifications of the Washington Department of Transportation which are by this reference incorporated herein and made a part hereof. The Contractor shall perform any alteration in or addition to the work provided in this contract and every part thereof. The Contractor shall complete the described work as follows: Contract time shall begin on the first working day following the Notice to Proceed Date. Beginning with the first working day, the project shall be physically complete within 100 working days. The Contractor shall provide and bear the expense of all equipment, work and labor of any sort whatsoever that may be required for the transfer of materials and for constructing and completing the work provided for in this contract and every part thereof. 2. The County of Jefferson hereby promises and agrees with the Contractor to employ, and does employ the Contractor to furnish the goods and equipment described and to furnish the same according to the attached specifications and the terms and conditions herein contained, and hereby contracts to pay for the same according to the attached specifications and the schedule of unit or itemized prices hereto attached, at the time and in the manner and upon the condition provided for in this contract. The County further agrees to employ the Contractor to perform any alterations in or additions to the work provided for in this contract that may be ordered and to pay for the same under the terms of this contract and the attached specifications at the time and in the manner and upon the conditions provided for in this contract. 3. The Contractor for himself, and for his heirs, executor, administrators, successors, and assigns, does hereby agree to the full performance of all the covenants herein contained upon the part of the Contractor. Construction Contract Contract G Version 1 Risk Legal Review Date 06/17/2020 Page I of 10 2- 2 P, 4. Prior to commencing work, the Contractor shall obtain at its own cost and expense the following insurance from companies licensed in the State with a Best's rating of no less than A: VII. The Contractor shall provide to the County Risk Manager certificates of insurance with original endorsements affecting insurance required by this clause prior to the commencement of work to be performed. The insurance policies required shall provide that thirty (30) days prior to cancellation, suspension, reduction or material change in the policy, notice of same shall be given to the County Risk Manager by registered mail, return receipt requested, for all of the following stated insurance policies. If any of the insurance requirements are not complied with at the renewal date of the insurance policy, payments to the Contractor shall be withheld until all such requirements have been met, or at the option of the County, the County may pay the renewal premium and withhold such payments from the moneys due the Contractor. All notices shall name the Contractor and identify the agreement by contract number or some other form of identification necessary to inform the County of the particular contract affected. A. Workers Compensation and Employers Liability Insurance. The Contractor shall procure and maintain for the life of the contract, Workers Compensation Insurance, including Employers Liability Coverage, in accordance with the laws of the State of Washington. B. General Liability (1) - with a minimum limit per occurrence of one million dollars ($1,000,000) and an aggregate of not less than two million dollars ($2,000,000) for bodily injury, death and property damage unless otherwise specified in the contract specifications. This insurance coverage shall contain no limitations on the scope of the protection provided and indicate on the certificate of insurance the following coverage: 1. Broad Form Property Damage with no employee exclusion; 2. Personal Injury Liability, including extended bodily injury; 3. Broad Form Contractual/Commercial Liability including completed operations (contractors only); 4. Premises - Operations Liability (M&C); 5. Independent Contractors and Subcontractors; and 6. Blanket Contractual Liability. (1) Note: The County shall be named as an additional insured party under this policy. C. Automobile (2) - with a minimum limit per occurrence of $1,000,000 for bodily injury, death and property damage unless otherwise specified in the contract specifications. This insurance shall indicate on the certificate of insurance the following coverage: 1. Owned automobiles; 2. Hired automobiles; and, 3. Non -owned automobiles. (2) Note: The County shall be named as an additional insured party under this policy. Any deductibles or self -insured retention shall be declared to and approved by the County prior to the approval of the contract by the County. At the option of the County, the insurer shall reduce or eliminate deductibles or self -insured retention or the Contractor shall procure a bond guaranteeing payment of losses and related investigations, claim administration and defense expenses. The Contractor shall include all subcontractors as insured under its insurance policies or shall furnish separate certificates and endorsements for each subcontractor. All insurance provisions for subcontractors shall be subject to all of the requirements stated herein. Construction Contract contmvt G Version 1 Risk Lagat lleview Dute 06/17/2020 @ago 2 of 10 Failure of the Contractor to take out and/or maintain any required insurance shall not relieve the Contractor from any liability under the Agreement, nor shall the insurance requirements be construed to conflict with or otherwise limit the obligations concerning indemnification. It is agreed by the parties that insurers shall have no right of recovery or subrogation against the County (including its employees and other agents and agencies), it being the intention of the parties that the insurance policies so affected shall protect both parties and be primary coverage for any and all losses covered by the above described insurance. It is further agreed by the parties that insurance companies issuing the policy or policies shall have no recourse against the County (including its employees and other agents and agencies) for payment of any premiums or for assessments under any form of policy. It is further agreed by the parties that any and all deductibles in the above described insurance policies shall be assumed by and be at the sole risk of the Contractor. It is agreed by the parties that judgments for which the County may be liable, in excess of insured amounts provided herein, or any portion thereof, may be withheld from payment due, or to become due, to the Contractor until such time as the Contractor shall furnish additional security covering such judgment as may be determined by the County. The County reserves the right to request additional insurance on an individual basis for extra hazardous contracts and specific service agreements. Any coverage for third party liability claims provided to the County by a "Risk Pool" created pursuant to Ch. 48.62 RCW shall be non-contributory with respect to any policy of insurance the Contractor must provide in order to comply with this Agreement. If the proof of insurance or certificate of coverage indicating the County is an "additional insured" to a policy obtained by the Contractor refers to an endorsement (by number or name) but does not provide the full text of that endorsement, then it shall be the obligation of the Contractor to obtain the full text of that endorsement and forward that full text to the County within 30 days of the execution of this Agreement. The County may, upon the Contractor's failure to comply with all provisions of this contract relating to insurance, withhold payment or compensation that would otherwise be due to the Contractor. 5. The Contractor shall comply with all Federal, State, and local laws and ordinances applicable to the work to be done under this Agreement. This Agreement shall be interpreted and construed in accord with the laws of the State of Washington and venue shall be in Jefferson County, WA. The Contractor shall defend, indemnify and hold the County, its officers, officials, employees, agents and volunteers (and their marital communities) harmless from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or resulting from the acts, errors or omissions of the Contractor in performance of this Agreement, except for injuries and damages caused by the sole negligence of the County. Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of the Contractor and the County, its officers, officials, employees, agents and volunteers (and their marital communities) the Contractor's liability, including the duty and cost to defend, hereunder shall be only to the extent of the Contractor's negligence. Claims against the County shall include, but not be limited to assertions that the use and transfer of any software, book, document, report, film, tape, or sound reproduction of material of any kind, delivered hereunder, constitutes an infringement of any copyright, patent, trademark, trade name, or otherwise results in an unfair trade practice or an unlawful restraint of competition. Construction Contract Contract G Version I Risk Legal Review Date 06/17/2020 Page 3 of 10 The Contractor specifically assumes potential liability for actions brought against the County by the Contractor's employees, including all other persons engaged in the performance of any work or service required of the Contractor under this Agreement and, solely for the purpose of this indemnification and defense, the Contractor specifically waives any immunity under the state industrial insurance law, Title 51 R.C.W. The Contractor recognizes that this waiver was specifically entered into pursuant to provisions of R.C.W. 4.24.115 and was subject of mutual negotiation. The provisions of this section shall survive the expiration or termination of this Agreement 6. The Contractor's relation to the County shall be at all times as an independent Contractor, and nothing herein contained shall be construed to create a relationship of employer -employee or master - servant, and any and all employees of the Contractor or other persons engaged in the performance of any work or service required of the Contractor under this Agreement shall be considered employees of the Contractor only and any claims that may arise on behalf of or against said employees shall be the sole obligation and responsibility of the Contractor. 7. The Contractor shall not sublet or assign any of the services covered by this contract without the express written consent of the County or its authorized representative. Assignment does not include printing or other customary reimbursable expenses that may be provided in an agreement. 8. Nothing in the foregoing clause shall prevent the County, at its option, from additionally requesting that the Contractor deliver to the County an executed bond as security for the faithful performance of this contract and for payment of all obligations of the Contractor. For contracts of $150,000 or less, the County and the Contractor may agree that in -lieu of the Contract Bond; the County will withhold 10% of the Contract amount in accordance with R.C.W 39.08.010. If applicable, the Contractor will indicate this option on Exhibit D. 9. The Contractor will declare a management option of the statutory retained percentage on Exhibit E, if applicable. -0 Limited Small Works Project per RCW 39.04.155(3): Performance Bond and Retainage Waived INDEX OF EXHIBITS Exhibit A: Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Exhibit B: Certification of Compliance with Wage Payment Statues Exhibit C: Contract Bond, Jefferson County, Washington Exhibit D: Contractor's Declaration of Option for Contracts for Less Than $150,000 XExhibit E: Contractor's Declaration of Option for Management of Statutory Retained Percentage Construction Contract Contract G Version I Risk Legal Review Date 06/17/2020 Page 4 of 10 IN WITNESS WHEREOF, the Contractor has executed this instrument on the day and year first below written, and the Board of County Commissioners has caused this instrument to be executed by and in the name of said County of Jefferson the day and year first above written. Executed by the Contractor A I 205?9, Contractor: Nordland Construction NW (Please print) By: (Please print) (Signature) 1oCOL-f.LyV�- K-� State of Washington, Contractor Registration Number COUNTY OF JEFFERSON BOARD OF COMMISSIONERS Dean, District I Z---^ Heidi EiqQnhour, District 2 District 3 Approved as to form only: PRE -APPROVED CONTRACT FORM Philip C. Hunsucker Date Chief ' y Prosecutor 3 sz Mo m ers, P.E. Date Public Works Director/County Engineer Construction Contract Contract G Version t Risk Legal Review Date 06/17/2020 Page 5 of 10 EXHIBIT A CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY, AND VOLUNTARY EXCLUSION The Contractor certifies to the best of its knowledge and belief, that it and its principals: (1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (2) Have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (3) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (2) of this certification; and (4) Have not within a 3-year period preceding this contract had one or more public transactions (Federal, State, or local) terminated for cause or default. Where the Contractor is unable to certify to any of the statements in this certification, such Contractor shall attach an explanation. Nordland Construction NW Name of Contractor (Please print) Name and Title of Authorized Representative (please print) Signature of Authorize Representative ❑ I am unable to certify to the above statement. An explanation is attached. Construction Contract Contract G Version 1 Risk Legal Review Date 06/17/2020 Page 6 of 10 EXHIBIT B CERTIFICATION OF COMPLIANCE WITH WAGE PAYMENT STATUTES I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. The undersigned bidder hereby certifies that, within the three-year period immediately preceding the bid solicitation date February 2, 2022 , the bidder is not a "willful" violator, as defined in RCW 49.48.082, or any of the provisions of chapters 49.46, 49.48, or 49.52 RCW as determined by a final and binding citation and notice of assessment issued by the Department of Labor and Industries or through a civil judgment entered by a court of limited or general jurisdiction. Nordland Construction NW Bidder's Business Name Signature of Authorized Official* Printed Name Title Date I City State Check One. - Sole Proprietorship Partnership Joint Venture Corporatio State of Incorporation, or if not a corporation, State where business entity was formed: If a co -partnership, give firm name under which business is transacted: * If'a corporation, proposal must be executed in the corporate name by the president or vice- president (or any other corporate officer accompanied by evidence of authority to sign). If a co- partnership, proposal must be executed by a partner. Construction Contract Contract 0 Version 1 Risk Legal Rovicw Dato 06/17/2020 Page 7 of 10 Bond No. 0243710 EXHIBIT C CONTRACT BOND JEFFERSON COUNTY, WASHINGTON KNOW ALL MEN BY THESE PRESENTS: That Nordland Construction NW , of Nordland, Washington as Principal, and Berkley Insurance Company , as Surety, are jointly and severally held and bound auto the COUNTY OF JEFFERSON, the penal sum of One million seven hundred forty-nine thousand twenty-one Dollars (S 1,749,021.00 ), for the payment of which we jointly and severally bind ourselves, or heirs, executors, administrators, and assigns, and successors and assigns, firmly by these presents. The condition of this bond is such that WHEREAS, on the 14th day of March , A.D., 2022 , the said Nordland Construction NW , Principal herein, executed a certain contract with the County of Jefferson, by the terms, conditions and provisions of which contract the said Nordland Construction NW , Principal herewith, agrees to furnish all materials and do certain work, to -wit: That the said Principal herein will undertake and complete the following described work: This Contract provides for the improvement of Thorndyke Road near milepost 4.71 by replacing the existing culverts with a new buried bridge, installation and removal of a temporary bypass road, structural earth walls, stream restoration, paving, guardrail, and other work in Jefferson County, Washington, as per maps, plans and specifications made a part of said contract, which contract as so executed, is hereunto attached, and is now referred to and by this reference is incorporated herein and made a part hereof as full for all purposes as if here set forth at length. NOW THEREFORE, if the Principal herein shall faithfully and truly observe and comply with the terms, conditions and provisions of said contract, in all respects and shall well and truly and fully do and perform all matters and things by the said Principal undertaken to be performed under said contract, upon the terms proposed therein, and within the time prescribed therein, and until the same is accepted, and shall pay all laborers, mechanics, subcontractors and materialmen, and all persons who shall supply such contractor or subcontractor with provisions and supplies for the carrying on of such work, and shall in all respects faithfully perform said contract according to law, then this obligation to be void, otherwise to remain in full force and effect. WITNESS our hands this 15th day of March , 20 22 Nordland Construction NW PRINCIPAL I-ft - . Berkley Insurance Company SURET CO Al�Y By. -- By: Melissa Wolf _ Attorney -in -fact Address of local office and agent of surety company: 501 N. Riverpoint Blvd., Suite 403, Spokane WA 99202 Construction Contract Contract G Version 1 Risk Legal Review Date 06/17/2020 Page 8 of 10 POWER OF ATTORNEY No, BlSurePath-a BERKLEY INSURANCE COMTANY WiLMiNGTON, DFL.AWARF. NOTICE: The warning found elsewhere in this Power of Attorney affects the validity thereof. Please review carefully. KNOW ALL MEN BY THESE PRESENTS, that BERKLEY INSURANCE COMPANY (the "Company"), a corporation duly organized and existing under the laws of the State of Delaware, having its principal office in Groenwich, CT, has made, constituted and appointed, and does by these presents make, constitute and appoint: Melissa Wolf Surety Bond No.: 0243710 PayneWest Insurance, Inc. Principal: Nordland Construction Northwest, Inc. Spokane, WA Obligee: Jefferson County Public Works Amount of Bond: See Bond Form its true and lawful Attorney -in -Fact, to sign its name as surety only as delineated below and to execute, seal, acknowledge and deliver any and all bonds and undertakings, with the exception of Financial Guaranty Insurance, providing that no single obligation shall exceed Fifty Million and 00/100 U.S. Dollars j(U.S.SM,000,000.00), to the same extent as if such bonds had been duly executed and acknowledged by the regularly elected officers of the Company at its principal office in their own proper persons. This Power of Attorney shall be construed and enforced in accordance with, arA governed by, the laws of the State of Delaware, without giving effect to the principles of conflicts of laws thereof. This Power of Attorney is granted pursuant to the following resolutions which were duly and validly adopted at a meeting of the Board of Directors of the Company held on January 25, 2010: RESOLVED, that, with respect to the Surety business written by Berkley Surety, the Chairman of the Board, Chief Executive Officer, President or any Vice President of the Company, in conjunction with the Secretary or any Assistant Secretary are hereby authorized to execute powers of attorney authorizing and qualifying the attonyey-in-fact named therein to execute bonds, undertakings, recognizances, or other suretyship obligations on behalf of the Company, and to affix the corporate seal of the Company to powers of attorney executed pursuant hereto; and said officers may remove any such attorney -in -fact and revoke any power of attorney previously granted; and further RESOLVED, that such power of attorney limits the acts of those named therein to the bonds, undertakings, recognizances, or other suretyship obligations specifically named therein, and they have no authority to bind the Company except in the manner and to the extent therein stated; and further RESOLVED, that such power of attorney revokes all previous powers issued on behalf of the attorney -in -fact named; and further RESOLVED, that the signature of any authorized officer and the seal of the Company may be affixed by facsimile to any power of attorney or certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligation of the Company; and such signature and seal when so used shall have the same force and effect as though manually affixed. The Company may continue to use for the purposes herein stated the facsimile signature of any person or persons who shall have been such officer or officers of the Company, notwithstanding the fact that they may have ceased to be such at the time when such instruments shall be issued. IN WITNESS WHEREOF, the Comps2 y has caused these presents to be signed and attested by its appropriate officers and its corporate seal hereunto affixed this ifay of t-1 i.r 00"14N` Attest: ise nsurance Company (Seal) `WtP € By SEAL Ir erman after Executive Vice President & Secretary e esident S7rA'rE OF CONNECrICUT ) ) ss: COUNTY OF FA1RFfELU ) Sworn to before me, a Notary Public in the State of Connecticut, thisa-f�411ay of , Q0 I by lru S. t.elcrmun and Jeffrey M. hatter who are sworn to me to be the Executive Vice Presiden Secreta , and N Senior Vice President, respectively, of Berkley Insurance Company. �� P N TICUT MY COI IM16$ION BXPIfS otary Public, State o Connecticut CERTIFICATE I, the undersigned, Assistant Secretary of BERKLEY INSURANCE COMPANY, DO HEREBY CERTIFY that the foregoing is a true, correct and complete copy of the original Power of Attorney; that said Power of Attorney has not been revoked or rescinded and that the authority of the Attorney -in -Fact set forth therein, who executed the bon&,>_,ing hich this Power of Attorney is attached, is in full force and effect as ofthis date. G,i en under my hand and seal of the Company, this 15th day of March2022 Seam ° {`aVincent .Fore 3F_Ai. EXHIBIT D CONTRACTOR'S DECLARATION OF OPTION FOR CONTRACTS FOR LESS THAN $1.50,000 A. A Contract Bond will be provided as required. Date Signed B. In lieu of providing a Contract Bond, the County will withhold 10% of the Contract amount. Date N I A Signed Construction Contract Contract G Version I Risk Legal Review Date 06/17/2020 Page 9 of 10 EXHIBIT E CONTRACTOR'S DECLARATION OF OPTION FOR MANAGEMENT OF STATUTORY RETAINED PERCENTAGE A. I hereby elect to have the retained percentage of this contract held in a fund by the Owner until (30) days following final acceptance of the work. Date �J l Signed B. I hereby elect to have the Owner deposit the retained percentage of this contract in an interest bearing account, not subject to withdrawal until after final acceptance of the work. Date Signed C. I hereby elect to have the Owner invest the retained percentage of this contract from time to time as such retained percentage accrues. I hereby designate said funds. as the repository for the escrow of I hereby further agree to be fully responsible for payment of all costs or fees incurred as a result of placing said retained percentage in escrow and investing it as authorized by statute. The Owner shall not be liable in any way for any costs or fees in connection therewith. Date Signed D. I hereby elect to provide a Retainage Bond in accordance with R.C.W 60.28.011. Date Signed Construction Contract Contract G Version 1 Risk Legal Review Date 06/17/2020 Page 10 of 10 ACORL�` NORDCON-02 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 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 endorsemen s). PRODUCER CONTACT Spokane Office PHONE - FA7( PayneWest Insurance, a Marsh McLennan Agency LLC Company ,_IE �No, Ext) (509) 838 3501 i lac, Nol (866) 226.3738 501 N. River Dint Blvd., Ste 403 ADDR�ss;. __-_ _ Spokane, WA 99202 __.... - - - -- - -- -- INSURER(S) AFFORDING COVERAGE ` NAIL A _ INSURER A: Alaska National Insurance Company _ 733 INSURED - I. INSURER B : - _-- Nordland Construction Northwest, Inc. L INSURERC_;_ — - - - —' P123 onderosa PI INSURER D Nordland, WA 98358 _ 'INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER- oCVICInAr KI uaDco. 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 I - �ADDL'SUBR} - - - - - l POLICY EFF i POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER LIMITS A X ' COMMERCIAL GENERAL LIABILITY -- J i' EACH OCCURRENCE $ Y i -' - --- - '- 1,000,000 CLAIMS -MADE X OCCUR X X ;21 E PS 11786 S/28/2021 - 5l28/2022 DAMAGE TO RENTED I . PREML6Fq U occyrrenceZ $.. -- 500,000 -- MEP EXP (AnY one person) i $_ .._ 15,000 - i ; .PERSONAL & ADV INJURY_, 1,000,000 N'L AGGREGATE LIT APPLIES PER: iCENERAL- AGGREGATE �-$.._._2.,_0.0_0 ,000 POLICY X PLOCJE .. PRODUCTS -OPAGG, $ . 2,000,000 AST OP A$ 1,000,000OTHER A AUTOMOBILE LIABILITY j j COMBINED SINGLE LIMIT - 1,000,000 X ANY AUTO i (21E AS 11786 512812021 { 5/2812022 ___ BODILY INJURY�Perperson) `$- jOWNED SCHEDULED AUTOS ONLY _4 AUTOS f j i FBODILYINJURYfPeraccident) $ HIR NON- AUT S ONLY AUTO � I _ R P OPEERTY DAMAGE Pera den 14 is A I X UMBRELLA LIAB X OCCUR 5,000,000 EXCESS LIAs CLAIMS -MADE 21 E LU 11786 OCCURRENCE, 5/28/2021 5/28/2022 5 000 000 E - r - DED X I RETENTION $ 10,0 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N j STR 1 A.LItIE._ __._.1 H _. I L------ - ER. j OFFICER/MEANY IMBOER EXCLUDED? ECUTIVE I ` �� andato in NH ry ) N /A ;.,E_L EACH ACCIDENT Ilfyes describe untler E.L._DISEASE,- EA EMPLOYEEF $__ . DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT ' $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES `ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Thorndyke Road MP 4.71 Culvert Replacement County Project No. 18020580 County Road No. 418708 Jefferson County is additional insured, on a primary/non-contributory basis, including waiver of subrogation, in accordance with the terms and conditions of the policy. Department of Public Works Jefferson County, Washington 623 Sheridan Street Port Townsend, WA 98368 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 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AV Alaska National INSURANCE COMPANY The insurance provided to such state e. Owners or Other Interests From or political subdivision does not apply Whom Land Has Been Leased to any "bodily injury", "property damage" or "personal and advertising An owner or other interest from whom injury" arising out of operations land has been leased by you but only performed for that state or political with respect to liability arising out of subdivision. the ownership, maintenance or use of that specific part of the land leased to b. Controlling Interest you and subject to the following additional exclusions: Any persons or organizations with a controlling interest in you but only This insurance does not apply to: with respect to their liability arising out of: (1) Any "occurrence" which takes place after you cease to lease (1) Their financial control of you, or that land; or (2) Premises they own, maintain or (2) Structural alterations, new con - control while you lease or occupy struction or demolition operations these premises. performed by or on behalf of such additional insured. This insurance does not apply to structural alterations, new construc- f. Co-owner of Insured Premises tion and demolition operations performed by or for such additional A co-owner of a premises co -owned insured. by you and covered under this insurance but only with respect to the c. Managers or Lessors of Premises co -owners liability as co-owner of such premises. A manager or lessor of premises but only with respect to liability arising out g. Lessor of Equipment of the ownership, maintenance or use of that specific part of the premises Any person or organization from leased to you and subject to the whom you lease equipment. Such following additional exclusions: person or organization is an additional insured only with respect to This insurance does not apply to: their liability for "bodily injury", "property damage" or "personal and (1) Any "occurrence" which takes Advertising injury' caused, in whole place after you cease to be a or in part, by your maintenance, oper- tenant in that premises; or ation or use of equipment leased to you by such person or organization. (2) Structural alterations, new con- A person's or organization's status as struction or demolition operations an additional insured under this performed by or on behalf of endorsement ends when their written such additional insured. contract or written agreement with you for such leased equipment ends. d. Mortgagee, Assignee or Receiver With respect to the insurance A mortgagee, assignee or receiver afforded these additional insureds, but only with respect to their liability the following additional exclusions as mortgagee, assignee, or receiver apply: and arising out of the ownership, maintenance, or use of a premises by This insurance does not apply: you. (1) To any "occurrence" which takes This insurance does not apply to place after the equipment lease structural alterations, new construc- expires; or tion or demolition operations performed by or for such additional insured. ANIC GL 1187 07 16 Page 2 of 6 Alaska National INSURANCE COMPANY This provision shall not increase the applicable Limits of Insurance shown in the Declaration. 2. Damage To Premises Rented to You SECTION III — LIMITS OF INSURANCE, Paragraph 6. is replaced by the following: 6. Subject to Paragraph 5. above, the Damage to Premises Rented to You Limit is the most we will pay under Coverage A for damages because of "property damage" to any one premises, while rented to you, or in the case of damage by fire, while rented to you or temporarily occupied by you with permission of the owner. If a limit is shown for Damage to Premises Rented to You the most we will pay under Coverage A for damages because or "property damage" to any one premises is the Limit shown in the Declarations or $500,000, whichever is greater. 3. MEDICAL PAYMENTS A. Section III — Limits of Insurance, Paragraph 7. is replaced by the following: 7. Subject to Paragraph 5. above the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person. If a limit is shown for Medical Expense in the Declarations the most we will pay under Coverage C for all medical expenses because of "bodily injury' sustained by any one person is the Limit shown in the Declarations or $15,000, whichever is greater. B. This provision 5. (Medical Payments) does not apply if Section I - Coverage C Medical Payments is excluded either by the provisions of the Coverage Part or by endorsement. C. Paragraph 1.a.(3)(b) of Section I - Coverage C - Medical Payments, is replaced by the following: (b) The expenses are incurred and reported to us within three years of the date of the accident; and 4. NON -OWNED WATERCRAFT A. If endorsement CG 21 09, CG 21 10, CG 24 50, or CG 24 51 is attached to the policy, Paragraph A. 2. g. (2) (b) is replaced by the following: (b) A watercraft that you do not own that is: (i) Less than 50 feet long: and (ii) Not being used to carry persons or property for a charge. B. If Paragraph A. does not apply, Paragraph g. (2) of 2. EXCLUSION under SECTION I — COVERAGES, COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following: (2) A watercraft that you do not own that is: (a) Less than 50 feet long; and (b) Not being used to carry persons or property for a charge. S. SUPPLEMENTARY PAYMENTS A. Under Section I - Supplementary Payments - Coverage A and B, Paragraph 1.b., the limit of $250 shown for the cost of bail bonds is replaced by $10,000; B. In Paragraph 1.d., the limit of $250 shown for daily loss of earnings is replaced by $500. 6. NEWLY FORMED OR ACQUIRED ORGANIZATIONS Paragraph 3.a. of Section If - Who Is An Insured is deleted and replaced by the following: Coverage under this provision is afforded only until the end of the policy period or the next anniversary of this policy's effective date after you acquire or form the organization, whichever is earlier. ANIC GL 1187 07 16 Page 4 of 6 ArAlaskaftVonal INSURANCE COMPANY 13. BLANKET WAIVER OF SUBROGATION The Transfer Of Rights Of Recovery Against Others To Us Condition (Section IV - Commercial General Liability Conditions) is amended by the addition of the following: We waive any right of against any person or payments we make for out of: recovery we may have organization because of injury or damage arising 1. Your ongoing operations; or 2. "Your work" included in the "products - completed operations hazard." However, this waiver applies only when you have agreed in writing to waive such rights of recovery in a contract or agreement, and only if the contract or agreement: 1. Is in effect or becomes effective during the term of this policy; and 2. Was executed prior to loss. 14. IN REM ACTIONS Any action in rem against any vessel owned, operated by or for, or chartered by or for you will be treated in the same manner as though the action were in personam against you. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective May 28, 2021 Insured Nordland Construction Northwest, Inc. Countersigned By Policy No. 21 E PS 11786 Endorsement No. 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission ANIC GL 1187 07 16 Page 6 of 6 Alaska ift oral INSURANCE COMPANY B. For all sums which the insured becomes legally C. obligated to pay as damages caused by "occurrences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical D. expenses shall reduce the amount available under the General Aggregate Limit or the Products -completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Designated Construction Project General Aggregate Limit. When coverage for liability arising out of the "products -completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of Section III — Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective May 28, 2021 Policy No. 21 E PS 11786 Insured Nordland Construction Northwest, Inc. Endorsement No. Countersigned By Feuf& R6>"s Inland Insurance/Spokane Valley ©insurance Services Office, Inc., 2008 CG 25 03 05 09 Page 2 of 2 at Alaska /Vatiohal INSURANCE COMPANY SECTION II — COVERED AUTO LIABILITY COVERAGE, Paragraph A.2.c. — Voluntary Property Damage is added as follows: c. Voluntary Property Damage At your written request, we may make a voluntary payment for Property Damage caused by an "insured", but without liability to a third party, up to $25,000. We will not make a Voluntary Property Damage payment to anyone who is an "insured" under this policy. SECTION III — PHYSICAL DAMAGE COVERAGE, Paragraph A.2. — Towing is replaced by the following. Towing We will pay up to $500 for towing and labor costs incurred each time a covered "auto" that is a: a. Private passenger; b. Truck; c. Pick-up truck; d. Panel; or e. Van type vehicle under 20,000 lbs. of Gross Vehicle Weight is disabled. However, the labor must be performed at place of disablement. SECTION III — PHYSICAL DAMAGE COVERAGE, Paragraph A.3. — Glass Breakage — Hitting a Bird or Animal — Falling Objects or Missiles is replaced by the following: Glass Breakage — Hitting a Bird or Animal — Falling Objects or Missiles If you carry Comprehensive Coverage for the damaged covered "auto", we will pay the following under Comprehensive Coverage: a. Glass Breakage; b. "Loss" caused by hitting a bird or animal; and c. "Loss" caused by falling objects or missiles. However, you have the option of having glass breakage caused by a covered "auto's" collision or overturn considered a "loss" under Collision Coverage. Glass Repair— Waiver of Deductible No deductible applies to glass breakage, if the glass is repaired rather than replaced. SECTION III — PHYSICAL DAMAGE COVERAGE, Paragraph AA.a. — Transportation Expenses is replaced by the following: a. Transportation Expenses We will pay up to $200 per day to a maximum of $1,500 for temporary transportation expense incurred by you because of the total theft of a covered "auto" that is a: (1) Private passenger; (2) Truck; (3) Pick-up truck; (4) Panel; or (5) Van type vehicle under 20,000 lbs. of Gross Vehicle Weight. We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes of Loss Coverage. We will pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expiration, when the covered "auto" is returned to use or we pay for its "loss". ANIC CA 1150 10 13 Page 2 of 4 Alaska National ationl (1) We will pay only for those expenses incurred during the policy period beginning 24 hours after the "loss" and ending, regardless of the policy's expiration, with the lesser of the following number of days: (a) The number of days reasonably required to repair or replace the covered "auto". (b) 30 days. (2) This coverage does not apply while there are spare or reserve "autos" available to you for your operations. (3) The Rental Reimbursement Coverage described above does not apply to a covered "auto" that is described or designated as a covered "auto" on Rental Reimbursement Coverage Form CA 99 23. SECTION IV — BUSINESS AUTO CONDITIONS — Paragraph B.2. — Concealment, Misrepresentation Or Fraud is amended by adding Unintentional Failure to Disclose Hazards at the end of Paragraph B.2. as follows: Unintentional Failure to Disclose Hazards If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. SECTION IV — BUSINESS AUTO CONDITIONS — Paragraph B.5.b. — Other Insurance is replaced by the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own: (1) Any covered "auto" you lease, hire, rent, or borrow; and (2) Any covered "auto"" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". SECTION V — DEFINITIONS — Paragraph C. — "Bodily injury" is replaced by the following: C. "Bodily injury" means bodily injury, sickness or disease sustained by a person including death or mental anguish resulting from any of these. Mental anguish means any type of mental or emotional illness or disease This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective May 28, 2021 Policy No. 21 E AS 11786 Insured Nordland Construction Northwest, Inc. Endorsement No. Countersigned By C Insurance Services Office, Inc., 2009 ANIC CA 1150 10 13 Page 4 of 4 Department of Public Works 0 Consent Agenda Page 1 of 1 Jefferson County Board of Commissioners Agenda Request To: Board of Commissioners Mark McCauley, hiefieftCounty Administrator From: Monte Reinders, Public Works Director/County Engineee;/� Agenda Date: April 11, 2022 �``'' Subject: Execution of Contract with Nordland Construction NW, Inc. Thorndyke Road MP 4.71 Culvert Replacement County Project No. 18020580, County Road No. 418708 RCO Project No. 20-1657R Statement of Issue: Execution of contract with Nordland Construction NW for the Thorndyke Road MP 4.71 Culvert Replacement, County Project No. 18020580. Analysis/Strategic Goats/Pro's Et Con's: Thorndyke Road MP 4.71 Culvert Replacement is a transportation improvement project included in the officially adopted 2022-2027 Transportation Improvement Program (TIP) as Item No. 7. The project will replace the fish barrier culverts at this location with a bridge. This contract is for construction of the new buried bridge. Fiscal Impact/Cost Benefit Analysis: The contract amount is $1,749,021.00. Construction will be funded at 85% ($1,486,668) by RCO, a $200,000 NFPP grant, and $62,353 from the County Road Fund. Recommendation: Public Works recommends that the Board execute all three (3) originals of the Contract with Nordland Construction NW and return two (2) originals to Public Works for further processing. Department Contact: Mark Thurston, Project Manager, 385-9210. Reviewed By: Mark McCaule , County Adminis a Da e CONTRACT REVIEW FORM Clear Form (INSTRUCTIONS ARE ON THE NEXT PAGE) CONTRACT WITH: Nordland Construction NW, Inc. Contract No-' aq OA;t e73'? Contract For: Thorndyke Road MP 4.71 Culvert Replacement Term: COUNTY DEPARTMENT: Public Works Contact Person: Mark Thurston, Chris Spall Contact Phone: EXL 210. Ed. 208 Contact email: mthurslon@co.jelfersonwaus, cspall0co.jeeerson.waus AMOUNT: $1,749,021.00 Revenue: Expenditure: Matching Funds Required: Sources(s) of Matching Funds Fund # Munis Org/Obj 180060010.33402.73.2058 595 yes 85% RCC, 11 % NF PP, 4% County Road Fund PROCESS: Exempt from Bid Process Cooperative Purchase Competitive Sealed Bid Small Works Roster Vendor List Bid RFP or RFQ Other: APPROVAL STEPS: STEP 1: DEPARTMENT CERTIFIES COMPLIANCE WITH JCC 3.55.080 AND CHAPTER 42.23 RCW. CERTIFIED: F N/A: ® � 3 12. 12 2 Signature Iate STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE COUNTY (CONTRACTOR) HAS NOT BEEN DEBARRED BY ANY FEDERAL, STATE, OR LOCAL AGENCY. CERTIFIED: F N/A: ❑ Signature Date STEP 3: RISK MANAGEMENT REVIEW (will be added electronically through Laserfiche): Electronically approved by Risk Management on 3/23/2022. STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche): electronically approved as to form by PAO on 3/30/2022. Pre -approved form. No PAO Signature needed. STEP 5: DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND PROSECUTING ATTORNEY(IF REQUIRED). STEP 6: CONTRACTOR SIGNS STEP 7: SUBMIT TO BOCC FOR APPROVAL