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HomeMy WebLinkAboutPW18-295 - Supplement - #4 - KBA, Inc. - East Valley Highway Pavement Preservation - 07/19/2018 Agreement Routing Form • For Approvals,Signatures and Records Management KENT This form combines&replaces the Request for Mayor's Signature and Contract Cover Sheet forms. WASHINGTON (Print on pink or cherry colored paper) Originator: Department: Kathi Kilborn for Eric Conner Public Works Engineering Date Sent: Date Required: > 6/4/2020 6/6/2020 O Authorized to Sign: Date of Council Approval: Q 0 Director or Designee ❑ Mayor Budget Account Number: Grant? ❑Yes ❑ No R90106 Budget? ❑Yes ❑ No Type: Vendor Name: Category: KBA, Inc. Vendor Number: Sub-Category: C O Project Name: EVH Pavement Preservation - S 180th St to S 196th St E = Project Details:Extension of Time only due to PSE Taking longer than expected to }, complete vault adjustment c a E Agreement Amount: Basis for Selection of Contractor: O IStart Date: 7/19/2018 Termination Date: 12/31/2020 Q Local Business? ❑Yes 0 No* *If meets requirements per KCC 3.70.700,please complete"Vendor Purchase-Local Exceptions"form on Cityspace. Notice required prior to disclosure? Contract Number: ❑Yes 0 No Date Received by City Attorney: Comments: p1 C n 30 a, •� i � 3 � 40 f0 p� Date Routed to the Mayor's Office: V1 Date Routed to the City Clerk's Office: adccW22313_1_20 Visit Documents.KentWA.gov to obtain copies of all agreements Washington State .Allift CDepartment of Transportation Supplemental Agreement Organization and Address Number 4 KBA,Inc. Original Agreement Number 11201 SE 8th St, Suite 160 LA 9212 Bellevue,WA 98004 Phone: 425 455-7920 Project Number Execution Date Completion Date STPUL-1073(005) 7/18/18 12/31/20 Project Title New Maximum Amount Payable East Valley Highway Pavement Preservation $226,1 19 Description of Work Extend the completion date to December 31, 2020 due to additional time is necessary to complete the project. The Local Agency of City of Kent _ desires to supplement the agreement entered in to with XHA, Inc. and executed on 7/19/18 and identified as Agreement No. -LA 9212 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 change to the scope of work. 11 Section IV, TIME FOR BEGINNING AND COMPLETION, is amended to change the number of calendar days for completion of the work to read: December 31, 2Q2- fll 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. Kristen M. Overleese By:_ BY:' - Consultant Signature pr ingfAuthority Signature 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 75/5/2020 E(MM/DDYYY) A�" CERTIFICATE OF LIABILITY INSURANCE /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(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 NAME: Dealey, Renton &Associates PHONE FAX P. O. Box 12675 AIC No Ext: 510-465-3090 AIC No):510-452-2193 Oakland CA 94604-2675 ADDRESS: certificates@dealeyrenton.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:XL Specialty Insurance Co. 37885 INSURED KBAINC INSURERB:The Phoenix Insurance Company 25623 KBA, Inc. 11201 SE 8th Street, Ste 160 INSURER C:The Travelers Indemnity Company of America 25666 Bellevue WA 98004 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:404410204 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY C X COMMERCIAL GENERAL LIABILITY Y Y 6806NO33449 5/10/2020 5/10/2021 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR PREM SES�RENTE a o_cur ence $1,000,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY jE LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y Y BA61\1034864 5/10/2020 5/10/2021 COMBINED SINGLE LIMIT $1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION Y 6806NO33449 5/10/2020 5/10/2021 PER AND EMPLOYERS'LIABILITY Y/N STATUTE ERH WA STOP GAP ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Professional Liability& DPR99959751 5/10/2020 5/10/2021 Per Claim $1,000,000 Contractor's Pollution Per Aggregate $1,000,000 Legal Liability DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Project 018014-01,Agreement#LA-9212, Fed Aid#STPUL-1073(005), East Valley Highway Pavement Preservation-South 180th Street to South 196th Street. The General Liability and Automobile Liability policies include an automatic Additional Insured endorsement that provides Additional Insured status to City of Kent,and the State of Washington,and their officers, employees,and agents,only when there is a written contract that requires such status,and only with regard to work performed on behalf of the named insured. The General Liability policy contains a special endorsement with Primary and Noncontributory wording,when required by written contract.The Automobile Liability policy contains a special endorsement with Primary wording,when required by written contract. The General Liability and Automobile Liability policies include a Waiver of Subrogation endorsement in favor of the Certificate Holder as referenced above. CERTIFICATE HOLDER CANCELLATION 30 Day Notice of Cancellation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Kent 400 West GOwe St. AUTHORIZED REPRESENTATIVE Kent WA 98032 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Policy: BA61\1034864 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following is added to Paragraph c. in A.1., Who between you and that person or organization, that is Is An Insured, of SECTION II — COVERED AUTOS signed by you before the "bodily injury" or "property LIABILITY COVERAGE in the BUSINESS AUTO damage" occurs and that is in effect during the policy COVERAGE FORM and Paragraph e. in A.1., Who Is period, to name as an additional insured for Covered An Insured, of SECTION II — COVERED AUTOS Autos Liability Coverage, but only for damages to LIABILITY COVERAGE in the MOTOR CARRIER which this insurance applies and only to the extent of COVERAGE FORM, whichever Coverage Form is that person's or organization's liability for the conduct part of your policy: of another"insured". This includes any person or organization who you are required under a written contract or agreement CA T4 37 02 16 ©2016 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.with its permission. POLICY NUMBER 6806N033449 COMMERCIAL GENERAL LIABILITY ISSUED DATE: 5/5/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Names of Additional Insured Person(s) or Organization(s): Any person or organization that you agree in a written contract, on this Coverage Part, provided that such written contract was signed and executed by you before, and is in effect when the "bodily injury"or"property damage" occurs or the "personal injury" or"advertising injury" offense is committed. Location of Covered Operations: Any project to which an applicable written contract with the described in the Name of Additional Insured Person(s)or Organization(s) section of this Schedule applies. (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) A. Section II — Who Is An Insured is amended to in- This insurance does not apply to "bodily injury" or clude as an additional insured the person(s) or "property damage" occurring, or "personal injury" organization(s) shown in the Schedule, but only or "advertising injury" arising out of an offense with respect to liability for"bodily injury", "property committed, after: damage", "personal injury" or "advertising injury" 1. All work, including materials, parts or equip- caused, in whole or in part, by: ment furnished in connection with such work, 1. Your acts or omissions; or on the project (other than service, mainte- 2. The acts or omissions of those acting on your nance or repairs) to be performed by or on behalf; behalf of the additional insured(s) at the loca- tion of the covered operations has been com- in the performance of your ongoing operations for pleted; or the additional insured(s) at the location(s) desig- nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- B. With respect to the insurance afforded to these tended use by any person or organization additional insureds, the following additional exclu- other than another contractor or subcontrac- sions apply: for engaged in performing operations for a principal as a part of the same project. CG D3 61 03 05 Copyright 2005 The St. Paul Travelers Companies, Inc. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 6806NO33449 ISSUED DATE: 5/5/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Any person or organization that you agree in a written contract to include as an additional insured on this Coverage Part for"bodily injury" or"property damage" included in the "products- completed operations hazard", provided that such contract was signed and executed by you before, and is in effect when, the bodily injury or property damage occurs. Location And Description Of Completed Operations Any project to which an applicable contract described in the Name of Additional Insured Person(s)or Organization(s)section of this Schedule applies. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- location designated and described in the schedule of clude as an additional insured the person(s) or or- this endorsement performed for that additional in- ganization(s) shown in the Schedule, but only with sured and included in the "products-completed opera- respect to liability for "bodily injury" or "property dam- tions hazard". age" caused, in whole or in part, by "your work" at the CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 COMMERCIAL GENERAL LIABILITY COVERAGE NAMED INSURED: KBA, Inc. POLICY NUMBER: 6806NO33449 ADDITIONAL COVERAGES BY WRITTEN CONTRACT OR AGREEMENT This is a summary of the coverages provided under the following forms (complete forms available): Excerpt from COMMERCIAL GENERAL LIABILITY COVERAGE (FORM #CG T1 00 02 19) SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS 4. OTHER INSURANCE - d. PRIMARY AND NON-CONTRIBUTORY INSURANCE IF REQUIRED BY WRITTEN CONTRACT: If you specifically agree in a written contract or agreement that the insurance afforded to an insured under this Coverage Part must apply on a primary basis, or a primary and non-contributory basis, this insurance is primary to other insurance that is available to such insured which covers such insured as a named insured, and we will not share with that other insurance, provided that: (1) The "bodily injury" or"property damage"for which coverage is sought occurs; and (2) The "personal and advertising injury" for which coverage is sought is caused by an offense that is committed; subsequent to the signing of that contract or agreement by you. Excerpt from XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS AND SURVEYORS (FORM #CG D3 79 02 19) PROVISION M. - BLANKET WAIVER OF SUBROGATION - WHEN REQUIRED BY WRITTEN CONTRACT OR AGREEMENT: If the insured has agreed in a written contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of: a. "Bodily injury" or"property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the signing of that contract or agreement. Page 1 AIPW TRAVELERSJ WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76(00)— 001 POLICY NUMBER: 6806NO33449 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA (BLANKET WAIVER) We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 3.00 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS OR ORGANIZATIONS THAT ARE PARTIE TO A CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT, PROVIDED YOU EXECUTED THE CONTRACT BEFORE THE LOSS. DATE OF ISSUE: 5/5/2020 ST ASSIGN: CA 017106