011-05 - WSDOT - Supplement / Change Order 4Aft Washington State
Depart rent of Transportation Local Agency Agreement Supplement
Agency Supplement Number
Port Orchard 4
Federal Aid Project Number Agreement Number CFDA No. 20.205
STPUS - 6610 004 LA 5855 (Catalon of Federal Domestic Assistance
The Local Agency desires to supplement the agreement entered into and executed on February 28, 2005
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:
Project Description
Name Tremont Street Widening Length 0.65 miles
Termini Port Orchard Boulevard to SR 16
Description of Work ® No Change
Reason for Supplement
Obligate funding.
Does this change require additional Right of Way or Easements? ❑ Yes ® No
Type of Work
yp
Estimate of Funding
(1)
Previous
A reement/Su i.
(2)
Supplement
(3)
Estimated Total
Project Funds
(4)
Estimated Agency
Funds
(5)
Estimated
Federal Funds
PE a.Agengy
86.5 % b.Other Consultant
3,000.00
3,000.00
405.00
2,595.00
677,000.00
677,000.00
91,395.00
585,605.00
c. Other
Federal Aid d. State
Participation
Ratio for PE e. Total PE Cost Estimate a+b+c+d
2,000.00
2,000.00
270.00
1,730.00
18,000.00
18,000.00
2,430.00
15,570.00
700 000.00
700,000.00
94,500.00
605,500.00
Right of Way f. AgencyAgengy
1,070,161.00
1,475,462.00
2.545.623.00
343,659.00
2,201,964.00
86.5 %Other50
000.00
50 000.00
6 750.00
43 250.00
Federal Aid h. Other
Participation
Ratio for RW i. State
'. Total RM Cost Estimate f+ +h+i
10 000.00
10 000.00
20 000.00
2,700.00
17 300.00
Construction k. Contract
I. Other
m. Other
n. Other
% o. A enc
Federal Aid
Participation P. State
Ratio for CN q. Total CN Cost Estimate k-i+m+n
r. Total Pro ect Cost Estimate e
The Local Agency further stipulates that pursuant to said Title 23, regulations and policies and procedures, and as a condition
to payment of the Federal fods obligated, rt epts and will comply with the applicable provisions.
Agency Official Washington State Department of Transportation
By
Title
By
Director of Highways and Local Programs
Date Executed
DOT Form 140-041 EA T T E S T
Revised 1/2007 ,
FatyiEfaar�. KIIi'kpatric
City of Port C ''Yhard
Public Works Department
216 Prospect Street, Port Orchard, WA 98366
Voice: (36o) 876-4991 • Fax: (36o)876-4980
Y y aarcher(@ciWobortorchard.us
www cityofportorchard.us
TO: Mr. Mark Brooks
WSDOT Highways and Local Programs
Olympic Region
5720 Capitol Blvd. SE
Tumwater, WA 98501-6703
WE ARE SENDING YOU
DATE: August 17, 2009 JOB NO.:
RE: Tremont Street Widening STPUS-6610(004)
❑ Drawings ❑ Plans ❑ Samples ■ Other LA Agreement Supplement
❑ Copy of Letter ❑ Revised Plans ❑ Specifications
COPIES JDATE NO. DESCRIPTION
2 08/11/09 Original Signed LA Agreement Supplement Number 4
THESE ARE TRANSMITTED AS CHECKED BELOW:
0 For Approval ❑Approved as submitted
❑ For your use
❑ As requested
❑ For review and comment
❑ Approved as noted
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Returned for corrections ❑ Return corrected prints
REMARKS Please forward the two originals to headquarters for approval and return one original to me when
complete. Thanks.
COPY TO
SIGNED
Andrea Archer, P. ., Assistant City Engineer