APPENDIX E: SAMPLE FORMS - Bothell WA

APPENDIX E: SAMPLE FORMS

E-2 2020 Deviation Request Form

E-3 Public – Bond Quantity Worksheet

E-14 ROW Dedication Deed Template

E-19 Utility Easement Template

Appendix E-1 2021 Update

DEVIATION REQUEST FROM DESIGN AND CONSTRUCTION STANDARDS AND SPECIFICATIONS

Project Name: Click or tap here to enter text. Permit No. Click or tap here to enter text.

Applicant: Click or tap here to enter text. Engineering Firm Name: Click or tap here to enter text.

Representative: Click or tap here to enter text.

Phone: Click or tap here to enter text.

Signature: Date:

Engineer: Click or tap here to enter text.

Phone: Click or tap here to enter text.

Signature: Date:

INSTRUCTIONS TO APPLICANT/DESIGN ENGINEER: Include a written request and justification and/or mitigation for the deviation along with plans, sketches, photos and maps, which may assist in complete review and consideration in accordance with Section 1-8, Deviation from Standards. Failure to provide all pertinent information may result in delayed processing or denial of your request. Submit this request form with your review submittal

APPLICABLE SECTION(S) OF STANDARDS AND JUSTIFICATION (see attached letter and site plan dated Click or tap here to enter text.):

1. Standard Drawing Enter Drawing number and description

2. Standard Section Enter Standards Section number and description of request

Applicant Information Above Agency Review Below

Public Works Director/Designee Date

Community Development Director/Designee Date

Fire Chief/Designee Date (Note NA if “Not Applicable” to Director/Fire Chief/Designee)

Director/Designee Determination

☐ Approval ☐ Conditional Approval (see below) ☐ Denial

CONDITIONS OF APPROVAL:

1. Click or tap here to enter text.2. Click or tap here to enter text.3. Click or tap here to enter text.


Bothell Public Works DepartmentSite Improvement Bond Quantity Worksheet

18415 101st Avenue NEBothell, WA 98011+1 (425)-788-3434

Project Name: Date:

Location: Project No.:

Clearing greater than or equal to 5,000 board feet of timber?

If yes, Forest Practice Permit Number:

(RCW 76.09)

Page 1 of 9

Complete Erosion Control & General Items Sheets first.

Cells highlighted in yellow are fillable by the applicant.

Note: All prices include labor, equipment, meterials, overhead and profit. Prices are from RS Means data adjusted for the Seattle area or from local sources if not included in the RS

Means database.

Yes No

Public - Bond Quantity Worksheet Other Final Plat Information available at http://bothellwa.gov

Unit prices updated: 06/21/17 Version: 04/22/02

Report Date: 1/5/2021Appendix E-3 2021 Update

No.Backfill & compaction-embankment ESC-1 8.40$ CYCheck dams, 4" minus rock ESC-2 SWDM 5.4.6.3 80.00$ EachCrushed surfacing 1 1/4" minus ESC-3 WSDOT 9-03.9(3) 95.00$ CYDitching ESC-4 10.50$ CYExcavation-bulk ESC-5 2.10$ CYFence, silt ESC-6 SWDM 5.4.3.1 1.58$ LFFence, Temporary (NGPE) ESC-7 1.58$ LFHydroseeding ESC-8 SWDM 5.4.2.4 0.80$ SYJute Mesh ESC-9 SWDM 5.4.2.2 3.50$ SYMulch, by hand, straw, 3" deep ESC-10 SWDM 5.4.2.1 2.63$ SYMulch, by machine, straw, 2" deep ESC-11 SWDM 5.4.2.1 2.00$ SYPiping, temporary, CPP, 6" ESC-12 12.00$ LFPiping, temporary, CPP, 8" ESC-13 17.85$ LFPiping, temporary, CPP, 12" ESC-14 22.05$ LFPlastic covering, 6mm thick, sandbagged ESC-15 SWDM 5.4.2.3 4.00$ SYRip Rap, machine placed; slopes ESC-16 WSDOT 9-13.1(2) 45.00$ CYRock Construction Entrance, 50'x15'x1' ESC-17 SWDM 5.4.4.1 1,837.50$ EachRock Construction Entrance, 100'x15'x1' ESC-18 SWDM 5.4.4.1 3,412.50$ EachSediment pond riser assembly ESC-19 SWDM 5.4.5.2 2,200.00$ EachSediment trap, 5' high berm ESC-20 SWDM 5.4.5.1 18.90$ LFSed. trap, 5' high, riprapped spillway berm section ESC-21 SWDM 5.4.5.1 73.50$ LFSeeding, by hand ESC-22 SWDM 5.4.2.4 1.00$ SYSodding, 1" deep, level ground ESC-23 SWDM 5.4.2.5 9.45$ SYSodding, 1" deep, sloped ground ESC-24 SWDM 5.4.2.5 11.55$ SYTESC Supervisor ESC-25 110.00$ HRWater truck, dust control ESC-26 SWDM 5.4.7 140.00$ HRTESC WRITE-IN-ITEMS

125.00$ Each

ESC SUBTOTAL: -$ 30% CONTINGENCY & MOBILIZATION: -$

ESC TOTAL: -$ Page 2 of 9 COLUMN: A

EROSION/SEDIMENT CONTROL

CostReference # Unit Price Unit Quantity

Storm Drain Inlet Protection


Unit prices updated: 06/21/17 Version: 04/22/02


Site Improvement Bond Quantity Worksheet

Unit Price Unit Quant. Cost Quant. Cost Quant. Cost Cost

GENERAL ITEMS No.Backfill & Compaction- embankment GI - 1 8.40$ CYBackfill & Compaction- trench GI - 2 12.60$ CYClear/Remove Brush, by hand GI - 3 1.00$ SYClearing/Grubbing/Tree Removal GI - 4 10,500.00$ AcreExcavation - bulk GI - 5 2.10$ CYExcavation - Trench GI - 6 5.25$ CYFencing, cedar, 6' high GI - 7 21.00$ LFFencing, chain link, vinyl coated, 6' high GI - 8 20.00$ LFFencing, chain link, gate, vinyl coated, 20' GI - 9 1,417.50$ EachFencing, split rail, 3' high GI - 10 18.90$ LFFill & compact - common barrow GI - 11 26.25$ CYFill & compact - gravel base GI - 12 28.35$ CYFill & compact - screened topsoil GI - 13 42.00$ CYGabion, 12" deep, stone filled mesh GI - 14 65.00$ SYGabion, 18" deep, stone filled mesh GI - 15 90.00$ SYGabion, 36" deep, stone filled mesh GI - 16 150.00$ SYGrading, fine, by hand GI - 17 2.63$ SYGrading, fine, with grader GI - 18 2.00$ SYMonuments, 3' long GI - 19 250.00$ EachSensitive Areas Sign GI - 20 15.75$ EachSodding, 1" deep, sloped ground GI - 21 9.45$ SYSurveying, line & grade GI - 22 1,260.00$ DaySurveying, lot location/lines GI - 23 2,100.00$ AcreTraffic control crew ( 2 flaggers ) GI - 24 120.00$ HRTrail, 4" chipped wood GI - 25 8.40$ SYTrail, 4" crushed cinder GI - 26 9.45$ SYTrail, 4" top course GI - 27 12.00$ SYWall, retaining, concrete GI - 28 55.00$ SFWall, rockery GI - 29 15.75$ SFWrite in custom items below

Page 3 of 9 SUBTOTAL

Quant Accepted

Assests Dedicated to the City (City use Only)Existing Right-of-way (Work

within ROW)

Future Public Road & Drainage Improvements

(Construction in ROW that will be completed after final

plat is issued)

Private Improvements (Project assests that will never be publicly owned)


Unit prices updated: 1.1.2020Version: 1.9.2020



Quant.

Unit Price Unit Quant. Cost Quant. Cost Quant. Cost Complete Cost

ROAD IMPROVEMENT No.AC Grinding, 4' wide machine < 1000sy RI - 1 30.00$ SYAC Grinding, 4' wide machine 1000-2000sy RI - 2 16.00$ SYAC Grinding, 4' wide machine > 2000sy RI - 3 10.00$ SYAC Removal/Disposal/Repair RI - 4 47.25$ SYBarricade, type I RI - 5 34.65$ LFBarricade, type III ( Permanent ) RI - 6 56.00$ LFCurb & Gutter, rolled RI - 7 17.00$ LFCurb & Gutter, vertical RI - 8 16.80$ LFCurb and Gutter, demolition and disposal RI - 9 18.00$ LFCurb, extruded asphalt RI - 10 5.50$ LFCurb, extruded concrete RI - 11 7.88$ LFSawcut, asphalt, 3" depth RI - 12 2.63$ LFSawcut, concrete, per 1" depth RI - 13 3.00$ LFSealant, asphalt RI - 14 2.00$ LFShoulder, AC ( see AC road unit price ) RI - 15 -$ SYShoulder, gravel, 4" thick RI - 16 15.00$ SYSidewalk, 4" thick RI - 17 38.00$ SYSidewalk, 4" thick, demolition and disposal RI - 18 32.00$ SYSidewalk, 5" thick RI - 19 41.00$ SYSidewalk, 5" thick, demolition and disposal RI - 20 40.00$ SYSign, handicap RI - 21 94.50$ EachStriping, per stall RI - 22 21.00$ EachStriping, thermoplastic ( for crosswalk/stop bar ) RI - 23 3.00$ SFStriping, 4" reflectorized line RI - 24 0.50$ LFWrite in custom items below



within ROW)



plat is issued)






Quant.


ROAD SURFACING (4" Rock = 2.5 base & 1.5" top course) (9 1/2" Rock=8" base & 1.5" top course)Additional 2.5" Crushed Surfacing RS - 1 3.60$ SYHMA 1/2" Overlay, 1.5" RS - 2 14.00$ SYHMA 1/2" Overlay, 2" RS - 3 18.00$ SYHMA Road, 2", 4" rock, First 2500 SY RS - 4 28.00$ SYHMA Road, 2", 4" rock, Qty. over 2500SY RS - 5 21.00$ SYHMA Road, 3", 9 1/2" Rock, First 2500 SY RS - 6 42.00$ SYHMA Road, 3", 9 1/2" Rock, Qty. over 2500 SY RS - 7 35.00$ SYHMA Road, 4", 6" Rock, First 2500 SY RS - 8 46.00$ SYHMA Road, 4", 6" Rock, Qty. over 2500 SY RS - 9 39.00$ SYHMA Road, 4", 12" Rock, First 2500 SY RS - 10 55.00$ SY

HMA Road, 4", 12" Rock, Qty. over 2500 SY RS - 11 48.00$ SY

HMA Road, 6" Depth, First 2500 SY RS - 12 33.10$ SYHMA Road, 6" Depth, Qty. over 2500 SY RS - 13 30.00$ SYHMA 3/4" or 1", 4" Depth RS - 14 20.00$ SYGravel Road, 4" Rock, First 2500 SY RS - 15 15.00$ SYGravel Road, 4" Rock, Qty. over 2500 SY RS - 16 10.00$ SYThickened Edge RS - 17 9.45$ LFWrite in custom items below




plat is issued)



within ROW)





Quant.


DRAINAGEAccess Road, R/D D - 1 23.10$ SYBollards - fixed D - 2 325.50$ EachBollards - removable D - 3 525.00$ Each*(CBs include frame and lid)CB Type I D - 4 1,575.00$ EachCB Type IL D - 5 1,837.50$ EachCB Type II, 48" diameter D - 6 2,520.00$ Each for additional depth over 4' D - 7 525.00$ FTCB Type II, 54" diameter D - 8 2,887.50$ Each for additional depth over 4' D - 9 682.50$ FTCB Type II, 60" diameter D - 10 3,255.00$ Each for additional depth over 4' D - 11 735.00$ FTCB Type II, 72" diameter D - 12 3,570.00$ Each for additional depth over 4' D - 13 787.50$ FTThrough-curb Inlet Framework (Add) D - 14 472.50$ EachCleanout, PVC, 4" D - 15 157.50$ EachCleanout, PVC, 6" D - 16 194.25$ EachCleanout, PVC, 8" D - 17 262.50$ EachCulvert, PVC, 4" D - 18 11.55$ LFCulvert, PVC, 6" D - 19 15.75$ LFCulvert, PVC, 8" D - 20 18.90$ LFCulvert, PVC, 12" D - 21 25.20$ LFCulvert, CMP, 8" D - 22 19.95$ LFCulvert, CMP, 12" D - 23 30.45$ LFCulvert, CMP, 15" D - 24 36.75$ LFCulvert, CMP, 18" D - 25 42.00$ LFCulvert, CMP, 24" D - 26 63.00$ LFCulvert, CMP, 30" D - 27 81.90$ LFCulvert, CMP, 36" D - 28 141.75$ LFCulvert, CMP, 48" D - 29 173.25$ LFCulvert, CMP, 60" D - 30 273.00$ LFCulvert, CMP, 72" D - 31 367.50$ LFWrite in custom items below


For Culvert prices, Average of 4' cover was assumed. Assume perforated PVC is same price as solid pipe.


within ROW)



plat is issued)






Quant.


DRAINAGE (CPP = Corrugated Plastic Pipe, N12 or Equivalent)Culvert, Concrete, 8" D - 32 26.25$ LFCulvert, Concrete, 12" D - 33 36.75$ LF

Culvert, Concrete, 15" D - 34 42.00$ LF

Culvert, Concrete, 18" D - 35 52.50$ LF

Culvert, Concrete, 24" D - 36 78.00$ LFCulvert, Concrete, 30" D - 37 141.75$ LFCulvert, Concrete, 36" D - 38 157.50$ LFCulvert, Concrete, 42" D - 39 173.25$ LFCulvert, Concrete, 48" D - 40 199.50$ LFCulvert, PVC, 6" D - 41 14.00$ LFCulvert, PVC, 8" D - 42 19.95$ LFCulvert, PVC, 12" D - 43 25.20$ LFCulvert, PVC, 15" D - 44 35.00$ LFCulvert, PVC, 18" D - 45 41.00$ LFCulvert, PVC, 24" D - 46 56.00$ LFCulvert, PVC, 30" D - 47 78.00$ LFCulvert, PVC, 36" D - 48 130.00$ LFDitching D - 49 9.50$ CYFlow Dispersal Trench (1,436 base+) D - 50 31.50$ LFFrench Drain (3' depth) D - 51 26.25$ LFGeotextile, laid in trench, polypropylene D - 52 3.15$ SYInfiltration pond testing D - 53 99.75$ HRMid-tank Access Riser, 48" dia, 6' deep D - 54 2,000.00$ EachPond Overflow Spillway D - 55 21.00$ SYRestrictor/Oil Separator, 12" D - 56 1,260.00$ EachRestrictor/Oil Separator, 15" D - 57 1,470.00$ EachRestrictor/Oil Separator, 18" D - 58 1,732.50$ EachRiprap, placed D - 59 47.25$ CYTank End Reducer (36" diameter) D - 60 1,260.00$ EachTrash Rack, 12" D - 61 350.00$ EachTrash Rack, 15" D - 62 410.00$ EachTrash Rack, 18" D - 63 480.00$ EachTrash Rack, 21" D - 64 550.00$ EachWrite in custom items below



within ROW)



plat is issued)


For Culvert prices, Average of 4' cover was assumed. Assume perforated PVC is same price as solid pipe.





Quant.

Unit Price Unit Quant. Cost Quant. Cost Quant. Cost Complete CostPARKING LOT SURFACING

No.2" AC, 2" top course rock & 4" borrow PL - 1 25.20$ SY2" AC, 1.5" top course & 2.5" base course PL - 2 28.00$ SY4" select borrow PL - 3 6.30$ SY1.5" top course rock & 2.5" base course PL - 4 18.90$ SY

SANITARY SEWERNo.

8" PVC Sewer line SS-1 78.75$ LF.SS Manhole (48") SS-2 2,520.00$ EachSS Manhole (60") SS-3 2,887.50$ EachSS Cleanout SS-4 472.50$ EachSS 6" (min.) Laterals SS-5 945.00$ Each

WATER LINENo.

8" Ductile Iron Pipe WA-1 47.25$ LF.12" Ductile Iron Pipe WA-2 68.25$ LF.Tee's & Bends WA-3 525.00$ EachWater Service Laterals WA-4 1,050.00$ Each8" Gate Valves WA-5 945.00$ Each12" Gate Valves WA-6 1,470.00$ EachFire Hydrant, bury and foot valve WA-7 3,150.00$ EachAir-vac assembly WA-8 2,625.00$ EachTie in with Existing Line WA-9 3,150.00$ EachPressure Reduction Vault w/assembly & controls WA-10 58,800.00$ Each

UTILITY POLES & STREET LIGHTINGNo.

Utility Pole(s) Relocation UP-1 LSStreet Light Pole w/Luminaires UP-2 7,500.00$ Each

WRITE-IN-ITEMSNo.

As-builts WI-1 5,000.00$ LS

SUBTOTAL

SUBTOTAL (SUM ALL PAGES):

30% CONTINGENCY & MOBILIZATION: NA

GRANDTOTAL: Page 8 of 9 COLUMN: B C D G


within ROW)



plat is issued)


Utility pole relocation costs must be accompanied by Franchise Utility's Cost Estimate




City of Bothell Site Improvement Bond Quantity Worksheet

Original bond computations prepared by:Name: Date:PE Registration Number: Tel. #:Firm Name:Address: Project No:

Stabilization/Erosion Sediment Control (ESC) (A)

Existing Right-of-Way Improvements (B)

Future Public Improvements (C)

Private Improvements (D)

(G)

Construction/Restoration Bond*/** (A+B)*1.2Minimum bond* amount is $1000.

(E-D)*1.2Performance Bond* Total ***

Maintenance/Defect Bond* Total

____ BOND REDUCTION: NAME OF PERSON PREPARING BOND* REDUCTION: Date:

* NOTE: The word "bond" as used in this document means any financial guarantee acceptable to the City of Bothell. ** NOTE: The construction/restoration bond shall include the total cost for all TESC as a minimum, not a maximum. In addition, corrective work, both on- and off-site needs to be included.

Quantities shall reflect worse case scenarios not just minimum requirements. For example, if a salmonid stream may be damaged, some estimated costs for restoration needs to be reflected in this amount. The 30% contingency and mobilization costs are computed in this quantity.

*** NOTE: Total bond amount shall not be less than 120% of the Exisitng and Future ROW and Drainage Improvements (B+C) or as revised by major design changes.SURETY BOND RIDER NOTE: If a bond rider is used, minimum additional performance bond shall be (C+D)-F

**** NOTE: The maintenance bond shall be reduced/released for project items following inspection and approval after 2 years from the construction/restoration or performance bond acceptance and released date.

REQUIRED BOND* AMOUNTS ARE SUBJECT TO REVIEW AND MODIFICATION BY THE CITY OF BOTHELLJUNE 2019 COST INCREASE APPLIED AT 1.05 TIMES 2017 COSTS

-$

-$

IMPROVEMENTS & DRAINAGE FACILITIES FINANCIAL GUARANTEE REQUIREMENTS - Complete Erosion Control & General Items Sheets prior to utilizing this sheet

-$

2-YEAR PUBLIC ROAD & DRAINAGE MAINTENANCE/DEFECT BOND*

REQUIRED AT RELEASE OF CONSTRUCTION/RESTORATION

BOND****

PERFORMANCE BOND* AMOUNT REQUIRED AT FINAL PLAT OR OCCUPANCY (FINAL LIFT ONLY)

***-$

-$

-$

CONSTRUCTION/ RESTORATION BOND*

AMOUNT

(B+C)*0.10 = -$

-$

-$

Page 9 of 9


Unit prices updated: 06/01/20Version: 1/4/2021


No.Quant

Accepted Cost

Signed this instrument, on oath stated that (he/she) was authorized to execute the instrument as the

City of Bothell Itemized Bill of Salefor infrastructure dedicated to the City

This Itemized Bill of Sale is to be submitted in conjunction with the City of Bothell's Public Works Agreement and Bill of Sale.

Assests Dedicated to the City

Description

Parcel Number(s): First Line of Legal Description:

I certify that I know or have satisfactory evidence that

And acknowledge it to be the free an Voluntary act of such party for the uses and purposes mentioned in the instrument.

Signature

Printed Name

Engineering Project No:

The Grantor,for and in consideration of which is hearby acknowledged grants and conveys to the City of Bothell the items as outlined below and in conjunction with the City of Bothell's Public Works Agreement. All of which have been connected to the existing system(s) being served by the City of Bothell and described as follows:


Dated this day of 20

Printed Name of Notary

My commission expires:

Signature of Notary


AFTER RECORDING RETURN TO: City of Bothell City Clerk Division 18415 101st Ave NE Bothell WA 98011 ______________________________________________________________________________

(Space above this line for recorder’s use only)

DOCUMENT TITLE: Right-of-Way Dedication Deed

REFERENCE NUMBER(S) OF RELATED DOCUMENTS:

Additional reference numbers on page(s) of document.

GRANTOR:

GRANTEE: City of Bothell

ABBREVIATED LEGAL DESCRIPTION:

See Exhibit A

Additional legal on page of document.

ASSESSOR'S TAX PARCEL NO(S).

RIGHT-OF-WAY DEDICATION DEED

THIS RIGHT-OF-WAY DEDICATION DEED is granted as of this ________ day of ____________________, 20___, by _______________________________ [corporate status or an individual(s)], hereinafter referred to as “Grantor,” to City of Bothell, a municipal corporation of the State of Washington, and its successors and assigns, hereinafter referred to as “Grantee.” The Grantor, for and in consideration of mutual benefit and other valuable consideration, hereby dedicates, conveys, assigns, and grants to the Grantee the real property situated in the County of ___________, in the State of Washington, described in the attached Exhibit A and as depicted in the attached Exhibit B, for all public right-of-way purposes, surface and subsurface, including but not limited to sidewalks, plantings, installation, operation, and maintenance of utilities, stormwater, and such other uses that municipalities may make of rights-of-way from time to time, now or in the future, for the use and benefit of the public over, under, upon, and across the real property described in the attached Exhibit A and depicted on Exhibit B. All such uses are unrestricted in location within the right-of-way and shall not be limited in any way whatsoever by the state of being, condition, or location of the street.


It is understood and agreed that the delivery of this Deed is tendered and that the terms and obligations hereof shall not become binding upon the Grantee unless and until accepted and approved in writing by the City of Bothell City Manager. IN WITNESS WHEREOF, this instrument has been executed the day and year first above written. GRANTOR: GRANTEE: [Insert Company Name], [corporate status]

City of Bothell, a Municipal Corporation

By: ________________________________ ________________________________ Its: ________________________________

By: ________________________________________ City Manager

APPROVED AS TO FORM:

By: ______________________________________ City Attorney

Exhibits: Exhibit A – Legal Description Exhibit B – Depiction

Certification

The undersigned duly appointed City Clerk for the City of Bothell, Washington, hereby certifies that the City Manager was authorized to accept this deed by Ordinance No. 1804 (2000) of the City Council. __________________________________ City Clerk


STATE OF WASHINGTON ) ) ss:

COUNTY OF __________ ) I certify that I know or have satisfactory evidence that [______________Name____________] is the person who appeared before me, and said person acknowledged that s/he signed the instrument, on oath stated that s/he was authorized to execute this instrument and acknowledged it as the [_____________Position/Title___________] of [_________Company_________], a [___________corporate status___________], to be the free and voluntary act of such party for the uses and purposes mentioned in the instrument.

DATED: ____________, 2020.

Print Name: NOTARY PUBLIC in and for the State of Washington, residing at My Appointment expires:

(Use this space for notarial stamp/seal)


Exhibit A – Legal Description


Exhibit B -Depiction


AFTER RECORDING RETURN TO: City of Bothell City Clerk Division 18415 101st Ave NE Bothell WA 98011 ____________________________________________________________________________________

(Space above this line for recorder’s use only)

DOCUMENT TITLE: Utility/Storm Drainage Easement

REFERENCE NUMBER(S) OF RELATED DOCUMENTS:

Additional reference numbers on page(s) of document.

GRANTOR:

GRANTEE: City of Bothell

ABBREVIATED LEGAL DESCRIPTION:

See Exhibit A

Additional legal on page of document.

ASSESSOR'S TAX PARCEL NO(S).

PROJECT:

UTILITY/STORM DRAINAGE EASEMENT

THIS UTILITY/STORM DRAINAGE EASEMENT is granted as of this ________ day of ____________________, 20___, by _______________________________ [corporate status or an individual(s)], hereinafter referred to as “Grantor,” to City of Bothell, a municipal corporation of the State of Washington, hereinafter referred to as “Grantee.” WHEREAS, the Grantor is the fee owner of that certain parcel of land situated in the County of ____________, State of Washington, described in the attached Exhibit A (“Property”), and desires to grant and convey a perpetual nonexclusive utility/storm drainage easement to Grantee. NOW, THEREFORE, for and in consideration of mutual and other non-monetary consideration, the Easement is granted subject to the following terms and conditions, which are covenants running with the land:

1. Grant of Easement. Grantor hereby grants and conveys to Grantee a perpetual non-exclusive easement on, under, across, over, and through that portion of Grantor’s property legally


described in the attached Exhibit B and graphically depicted in the attached Exhibit C (the “Easement Area”), for any and all types of utility infrastructure and related facilities (including without limitation water, sewer, stormwater, electrical, telecommunications, fuels, etc. that are now or may be owned and/or operated by the Grantee over, under, upon, and across the Property) and for all utility purposes (including but not limited to locating, designing, constructing, installing, using, inspecting, surveying, protecting, maintaining, repairing, replacing, modifying, upgrading, and removing any utility/stormwater infrastructure and facilities and any related facilities, appurtenances, or elements).

2. Easement Rights. Grantee shall have the rights of use and occupancy for utility/storm

drainage purposes as described above, and in addition shall have the right to clear and keep cleared all trees and other obstructions from the Easement Area; the right of ingress and egress over and across the land of the Grantor to and from the above-described property; and the right to engage in any other activity on, under, across, over, and through the Easement Area that is reasonably related to the utilities.

3. Easement Area to Remain Clear.

a. Grantor covenants to refrain from placing, planting, or maintaining landscaping and vegetation in, on, under, or above the surface of Easement Area, except that Grantor may plant and maintain low-growth landscaping and vegetation, such as bushes, lawn, and other shallow-rooted shrubberies, in the Easement Area. Grantor must first obtain Grantee’s written consent, which shall not be unreasonably withheld, to install landscaping. Trees and other major vegetation are not permitted in the Easement Area.

b. Grantor covenants to refrain from placing, locating, constructing, installing, or maintaining buildings, structures (including, but not limited to fences, decks, sheds, and/or patios), or other impediments, objects, or tangible things in, on, under, or above the surface of Easement Area and/or any areas delineated by applicable building setback lines unless the objects or things do not unreasonably interfere with Grantee’s rights hereunder. Grantor must first obtain Grantee’s written consent, which shall not be unreasonably withheld, to install any such items.

4. Run with the Land. The agreements, easements, rights, conditions, and provisions granted

and conveyed herein shall be deemed covenants running with the land and shall inure to the benefit of and be binding upon the successors, assigns, heirs, executors, and administrators of the parties.

SIGNATURE(S) ON NEXT PAGE


IN WITNESS WHEREOF, this instrument has been executed the day and year first above written. GRANTOR: GRANTEE: [Insert Company Name], [corporate status] City of Bothell, a Municipal Corporation

____________________________________ By: ________________________________________ City Manager Its:__________________________________

APPROVED AS TO FORM:

By: ______________________________________ City Attorney

Exhibits: Exhibit A – Legal Description of Property Exhibit B – Legal Description of Easement Area Exhibit C – Depiction of Easement Area

Certification

The undersigned duly appointed City Clerk for the City of Bothell, Washington, hereby certifies that the City Manager was authorized to accept this deed by Ordinance No. 1804 (2000) of the City Council. __________________________________ City Clerk


STATE OF WASHINGTON COUNTY OF __________ I certify that I know or have satisfactory evidence that ___________________________ is the person who appeared before me, and said person acknowledged that he/she signed the instrument and acknowledged it to be his/her free and voluntary act for the uses and purposes mentioned in the instrument.

DATED: _______________, 2020.

Print Name: NOTARY PUBLIC in and for the State of Washington, residing at My Appointment expires:

(Use this space for notarial stamp/seal)


APPENDIX E: SAMPLE FORMS - Bothell WA

Documents