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Appendix 22.53 Local Agency Agreement Supplement DRAFT '7' Lcal Agency Agreement Supplement newat"importation '9"? uppernent'num or sm "i'i "rOieciu er amenU-um creme. 20.205 C M tit-+0 060 LA 8% (CatalogotFederai DomesticAssistance) The Local Agency requests to supplement the agreement entered into and executed on All provisions In the basic agreement remain In effect except as modied by this supplement. The change to the agreement are as follows: Project Description ,- .- p _ plidid m Z. Name Pujet- Sound Rejionql "CU-4'1 "Wk my", Termini Description of Work ENo Change Reason for Supplement tag ":5; Luj'i est-:Mcvk - >11: F1 790%; +0 1m rea 3:: {.m cl; m can hw; but} no he+ inc revise. Are you claiming indirect cost rate? [3 Yes E No Project Agreement End Date l 1- 3 i - / Q; Does this change require additional Right of Way or Easements? 7:] Yes E5 No Advertisement Date: ttmate of Fundin (1) (3) (4) (5) Type f Wrk Previous (gm EstimatedTotal EstimatedAgency Estimated Federal 3" AreernentlSu I. "9 Precl Funds Funds Funds P 000 _ .. "an % om tom Participation ' ' 00 _ RatiolorPE . A- ' l t I' ". 0.00 _ h'to % ow _ . ... PM" tL_Qttl Participation Worm -- at. .t _000 WWW .Al .F.". om _ % . 'TrucKi' 0n .v om o-oo __000 Liv um 27350 Woo , 0 am 3 can: u I it' s' . 4' 5 0 000 '6' "0 6C) m JO 53mg" -. . 000 000 t a. m. 1- a is - RatiotorCN mm . 000 mum-rm .5 11> m _ _ ' 1.57 81 n 757 3;, I'm_ 6 ',-. l 'r ..'ll.'.l; C; 5' l . ultul 'u' (- w ' 5 .1'1'1 ' 32/ gal 's.' '1' 4'": '11" 73' d/'j' 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 funds obligated. it accepts and will comply with the applicable provisions. Agency Ofcial Washington State Department of Transportation By By Tltle Director, Local Program Dale Executed DOT Form 140-041 Page t Revised 05/2015 WSDOT LocalAgency Guidelines M 36453.31 Page 22-13 April 2016
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