HomeMy WebLinkAboutCAG2021-092 - Original - Washington Traffic Safety Commission - Application for Pacific Highway (SR99) Walker and Roller Safety Program - 10/01/2021ApprovalOriginator:Department:
Date Sent:Date Required:
Authorized to Sign:
o Director or Designee o Mayor
Date of Council Approval:
Budget Account Number:
Budget? o Yes o No
Grant? o Yes o No
Type:Review/Signatures/RoutingDate Received by City Attorney:Comments:
Date Routed to the Mayor’s Office:
Date Routed to the City Clerk’s Office:Agreement InformationVendor Name:Category:
Vendor Number:Sub-Category:
Project Name:
Project Details:
Agreement Amount:
Start Date:
Basis for Selection of Contractor:
Termination Date:
Local Business? o Yes o No*
*If meets requirements per KCC 3.70.100, please complete “Vendor Purchase-Local Exceptions” form on Cityspace.
Notice required prior to disclosure?
o Yes o No
Contract Number:
Agreement Routing Form
For Approvals, Signatures and Records Management
This form combines & replaces the Request for Mayor’s Signature and Contract Cover Sheet forms.
(Print on pink or cherry colored paper)
Visit Documents.KentWA.gov to obtain copies of all agreementsadccW22373_1_20
Walker andlor Roller Safety Enhancement Projects Application Packet
1A - Applicant lntake Form (Mandatory Document)
Summary
Project Title Pacific Highway (SR 99) Walker and Roller Safety Progran
Project Period - How long
a period are you asking for
project support?
Please check one box
X 12-month project period (October 1 ,2021 - September
30,2022)
fl 24-month project period (October 1,2021 - September
30,2023)
Project Manager
First Name Sara
Last Name Wood
Title Target Zero Manager - Region 8
Organization Kent Police Department
Address 22O 4th Avenue South
City Kent
Zip Code 98032
Telephone 253-856-5856
Email swood@kentwa.gov
Authorizing Official (Person with contracting authority)
First Name Dana
Last Name Ralph
Title Mayor
Organization:City of Kent
23 of 4Q
Address:220 4th Avenue South
City:Kent
Nine-digit Zip Code 98032-5838
Telephone 253-856-5700
Email dralph@kentwa.gov
Federal Employer Tax ldentification
number:91-6001254
State of Washington Vendor (S\4ru)
number for applicant organization: 1
Provide either the SWV number or the
date the SWV application was
submitted.
0000552-00
Federal DUNS number for applicant
organization:
020253613
Walker andlor Roller Safety Enhancement Projects Application Packet
Sionature Date
Title MayorPrinted Name Dana Ralph
1lf the Applicant does not currently an SWV number, they will need to apply for one using the forms
found at https://ofm.wa.sovlit-svstems/accounting-svstems/statewide-vendorpavee-services, Vendor/Payee
Registration Form.
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1B - Certifications and Assurances (Mandatory Document)
Walker andlor Roller Safety Enhancement Projects Application Packet
l/we make the following certifications and assurances as a required element of the
application to which it is attached, understanding that the truthfulness of the facts
affirmed here and the continuing compliance with these requirements are conditions
precedent to the award or continuation of the related contract:
l/we declare that all answers and statements made in the application are true and
correct.
1. The prices and/or cost data have been determined independently, without
consultation, communication, or agreement with others for the purpose of restricting
competition. However, l/we may freely join with other persons or organizations for
the purpose of presenting a single application.
2. The attached Application is a firm offer for a period of 120 days following receipt,
and it may be accepted by WTSC without further negotiation (except where
obviously required by lack of certainty in key terms) at any time within the 120-day
period.
3. ln preparing this application, l/we have not been assisted by any current orformer
employee of the state of Washington whose duties relate (or did relate) to this
application or prospective contract, and who was assisting in other than his or her
official, public capacity. lf there are exceptions to these assurances, l/we have
described them in full detail on a separate page attached to this document.
4. l/we understand that WTSC will not reimburse me/us for any costs incurred in the
preparation of this application. All applications become the property of WTSC,and
l/we claim no proprietary right to the ideas, writings, items, or samples, unless so
stated in this Application.
5, Unless otherwise required by law, the prices and/or cost data which have been
submitted have not been knowingly disclosed by the Applicant and will not
knowingly be disclosed by him/her prior to opening, directly or indirectly, to any
other Applicant or to any competitor.
6. l/we agree that submission of the attached application constitutes acceptance of the
solicitation contents and the attached sample contract and generalterms and
conditions. lf there are any exceptions to these terms, l/we have described those
exceptions in detail on a page attached to this document.
7. No attempt has been made or will be made by the Applicant to induce any other
person or organization to submit or not to apply for the purpose of restricting
competition.
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Walker andlor Roller Safety Enhancement Projects Application Packet
8. l/we grant WTSC the right to contact references and others who may have pertinent
information regarding the ability of the Applicant and the lead staff person to perform
the services contemplated by this RFP.
9. lf any staff member(s) who will perform work on this contract has retired from the
state of Washington under the provisions of the 2008 Early Retirement Factors
legislation, his/her name(s) is noted on a separately attached page.
On behalf of the Applicant submitting this applicatioh, ffiy name below attests to
the accuracy of the above statement. We are submitting a scanned signature of
this form with our Application.
Sionature
Printed Name Dana Ralph
Date
Title Mayor
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1C - Contractor Certification for Executive Order 18-03 (Mandatory
Document)
Walker andlor Roller Safety Enhancement Projects Application Packet
WORKERS' RIGHTS - WASHINGTON STATE GOODS & SERVICES CONTRACTS
Pursuant to the Washington State Governor's Executive Order 18-03 (dated June 12,
2018), the Washington Traffic Safety Commission is seeking to contract with qualified
entities and business owners who certify that their employees are not, as a condition of
employment, subject to mandatory individual arbitration clauses and class or collective
action waivers.
SOLICITATION: Prevention Community-Based Enhancement Grants RFP #: 3882
I hereby certify, on behalf of the organization identified below, as follows (check one):
X No Mandatory lndividual Arbitration Clauses and Class or Gollective Action
Waivers for Employees. This organization does NOT require its employees, as a
condition of employment, to sign or agree to mandatory individual arbitration clauses
or class or collective action waivers.
OR
tr Mandatory lndividual Arbitration Glauses and Class or Collective Action
Waivers for Employees. This organization requires its employees, as a conditionof
employment, to sign or agree to mandatory individual arbitration clauses or class or
I hereby certify, under penalty of perjury under the laws of the state of Washington, that
the certifications herein are true and correct and that I am authorized to make these
certifications on behalf of the organization listed herein.
AGENCY/SCHOOL/ORGAN IZATI ON NAM E:
Citv of Kent
@ame of Agency/School/organization
Signature Date
MayorDana Ralph
Printed Name Title
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