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Washington State <br />M A P Department of Transportation <br />Paula J. Hammond <br />Secretary of Transportation <br />Northwest Region <br />Sno -King Local Agency and Development Services <br />15700 Dayton Ave. N <br />P.O. Box 330310 12 -011 <br />Seattle, WA 98133 Council Approval N/A <br />APPLICATION FOR JA ACCOUNT <br />Robin Tischmak, City Engineer <br />City of Tukwila Public Works <br />6300 Southcenter Blvd., Suite 100 <br />Tukwila, WA 98188 <br />February 6, 2012 <br />Subject: SR 5 NB Offramp Signing <br />Dear Mr. Tischmak: <br />City File No: W1 0 I <br />A charge account number, JA -7677, has been opened by this office to cover WSDOT's actual costs for <br />reviewing submitted engineering data and plans, as well as construction inspection and preparation of an <br />airspace lease. <br />PROJECT TITLE: Tukwila Urban Access (Klickitat) <br />LOCATION: SR 5 NB Off Ramp MP 154 vic <br />DESCRIPTION OF WORK: Engineering sign design, review and construction inspection within WSDOT <br />right of way. <br />ESTIMATE COST: Approximately: $10,000.00 (actual costs may vary; written approval from <br />developer is required prior to exceeding estimate) <br />By filling out and signing the application, the City of Tukwila Public Works, agrees to pay all WSDOT <br />costs related to your proposed improvement, including administrative costs until this project is accepted by <br />WSDOT as complete. Please do not send funds at this time, an invoice will be submitted to you each <br />month with the charges that are incurred. Payment is due within 30 days of receipt of each invoice. Interest <br />of 1% per month may be charged on past due accounts. <br />City of Tukwila Public Works <br />Developer Agency Name <br />6300 Southcenter Blvd <br />Billing Address <br />Suite or Office Number <br />Tukwila, WA 98188 <br />206 433 -0179 <br />Phone Number <br />91- 6001519 <br />Federal ID Number or SSN <br />Jim Haggerton <br />Authorized Representative (Please Print or Type) <br />Mayor <br />City, State, Zip code Title <br />To avoid delays, please return this c ZPX d ap plt� n as soon as possible, to the following address: <br />Washington State De t of Transportation <br />Attention: Felix Palisoc <br />Local Agency and Development Services, MS 240 <br />P.O. Box 330310 <br />Seattle, WA 98133 <br />If you have any questions, please feel free to contact Felix Palisoc, of our Development Services section at <br />(206) 440- 4713 or via email at nalisof(awsdot.wa.Eov. <br />Sincerely, <br />Ramin Pazooki <br />Local Agency and Development Services Manager <br />For Department Use Only <br />Felix Palisoc 412463 JA 7677 0910 <br />WSDOT Representative Org Number Job Number Work Op <br />WAPW Eng\PROJECTS\A- RW RS Projects \98410419 TUC Access Klickitat )VA7677_SRSNBrampSign.doc <br />