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Protect No. 112 <br />Program No, <br />Function No. <br />Service No. <br />Planning Unit <br />Permit No: <br />PROJECT COST ESTIMATE /REQUEST AND CLOSURE FORM <br />Return to Roads Finance: <br />Attn: Marc Walsh <br />MS: KSC -TR -0315 <br />Project Title: LBridge Inspection City of Tukwila - UBIT <br />Project Location: iVarious location in the City of Tukwila <br />f { KC Road Log <br />t t Number: <br />1 <br />Project Type: Reimbursable org: 5626 Division No: <br />Related CIP <br />Project No: <br />Start Year: 2016 Start Date:! 2/1 /16 <br />Is this a multi- <br />year project - <br />Ves/No: <br />No <br />Estimated <br />year of final <br />completion: <br />12/31/2016 <br />PROJECT DESCRIPTION: <br />TASK <br />UBIT Inspection.on Bridge Tuk -15 <br />Provide inspection reports to WSDOT and the city after completion of the inspections. <br />55.02.08 <br />55.02.08 <br />TASK DESCRIPTION: <br />Estimated protect expenditures by year: <br />2016 <br />$3,985.00 <br />2017 i i 2019 <br />Bridge Inspection <br />$1,340.00 <br />Administration, Tech support, Report Prep, FC Rept <br />90.00.34 <br />$730.00 <br />Vendor Equipment <br />Railroad Flagger <br />$1,650.00 <br />Equipment <br />$55.00 <br />AIRS CUSTOMER NUMBER: 73- <br />BR: SR: <br />Contingency <br />$210.00 <br />TOTAL: $3,985.00 <br />** <br />LABOR: <br />ER &R EQUIPMENT: <br />VENDOR EQUIPMENT: UBIT <br />RR FLAGGING: <br />CONTRACT: <br />TOTALS: <br />ESTIMATED: <br />$2,070.00 <br />$55.00 <br />$1,650.00 <br />ACTUAL: <br />$210.00 <br />$3,985.00 <br />$0.00 <br />OPEN SIGNATURES: (REQUIRED) CLOSURE DATE <br />REQUESTOR: NAME: I DATE: i E <br />AUTHORIZER: NAME: - { DATE: 1 <br />FIELD PROCESSING: NAME: DATE: <br />FINANCE PROCESSING: NAME: DATE: <br />** *REQUIRED FIELDS IF PROJECT IS REIMBURSABLE * * * * ** <br />Enter Customer Billing Information below <br />Customer Contact Name: 1 Robin Tischmak, Senior Transportation Engineer <br />Customer Billing Company Name: City of Tukwila <br />Customer Billing Address No. 1: 6300 Southcenter Blvd. Suite 100 <br />Customer Billing Address No. 2: Tukwila, WA 98188 -2544 <br />Customer Contact Phone Number: 206 - 433 -0179 <br />(REQUIRED) (REQUIRED) <br />Roads Project Mgr: Margaret Holwegner jRoads PM Phone No: <br />206 -477 -3539 <br />CLOSURE SIGNATURES: <br />REOUESTOR: NAME: <br />AUTHORIZER: NAME: <br />FIELD PROCESSING: NAME: <br />FINANCE PROCESSING: NAME: <br />(REQUIRED) CLOSURE DATE. <br />DATE: <br />DATE: <br />DATE: <br />DATE: <br />ROADSCEFORM.XLS <br />REV 8/1/2010 <br />