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Resolution No. 2022-035Rdii CLE - M, CITY OF CLERMONT .f fRESOLUTION N0.2022-035R A RESOLUTION OF THE CITY OF CLERMONT CITY COUNCIL MAKING APPROPRIATE FINDINGS FOR CERTAIN PRIVATE AND NON -CITY MAINTAINED ROAD DEBRIS REMOVAL WITHIN THE CITY OF CLERMONT, LAKE COUNTY, FLORIDA; AUTHORIZING THE CITY MANAGER TO PURSUE REIMBURSEMENT AS APPLICABLE FROM THE FEDERAL EMERGENCY MANAGEMENT AGENCY AND PROVIDING FOR AN EFFECTIVE DATE. WHEREAS, on September 24, 2022, the Governor of the State of Florida executed Executive Order 22-219, declaring a state of emergency in every County within the State of Florida in preparation for Hurricane Ian; and WHEREAS, on September 25, 2022, the Lake County Board of County Commissioners issued Executive Order 2022-01 declaring local state of emergency for Lake County; WHEREAS, on September 25, the Mayor of the City of Clermont issued Resolution No. 2022-34R declaring a local state of emergency for the City of Clermont, Florida; WHEREAS, it is anticipated that Hurricane Ian will bring significant rain and wind to the City of Clermont and will result in substantial amount of storm debris on or about private and non - city maintained roadways within the City of Clermont. NOW, THEREFORE, BE IT RESOLVED by the Mayor of the City Council of the City of Clermont, Florida, Lake County, Florida as follows: Section 1. The foregoing recitals are true and correct and hereby incorporated by reference. Section 2. The City Council of the City of Clermont does hereby determine and find as follows: A. It is in the public interest to have debris removed from specified private roads and rights - of -way in order to eliminate immediate threats to life, public health and safety, to eliminate threats of significant damage to improved property, and to ensure the economic recovery of the affected community to benefit the community -at -large. B. The City as provided by its home rule authority and the State of Florida under Section 252.38, Florida Statutes and as discussed in one or more opinions of the State of Florida Attorney General, including Attorney General Opinion Numbers 98-22 and 2012-33, has the legal responsibility and authority in the public interest to remove such hurricane -generated debris from private property. 63 CLER bNT CITY OF CLERMONT �--�� RESOLUTION NO.2022-035R C. Based upon the above and all other available facts and circumstances, the City Council authorizes the entering onto specified private roads and rights -of -way in order to abate the declared public health nuisance and safety emergency by removing the hurricane generated debris from those right of ways. Section 3. In accordance with the above findings and determination the following shall apply: A. Before it initiates hurricane -generated debris removal, the City shall have satisfied all applicable legal requirements and/or received all legal permissions to carry out these actions of debris removal through the use of appropriate agreements as approved by the City Attorney, including at a minimum, with indemnification clauses signed by the Homeowners Association, or if no Homeowners Association, by each property owner/lessor that uses said specified private road. B. As required by, and only to the extent required by, section 407(b) of the Stafford Act (42 U S.C. 5173(b)), the City of Clermont hereby agrees, to the extent allowed by state and federal law, that it shall indemnify and hold harmless the Federal Government and its respective employees, agents, contractors, and subcontractors from any claims arising from debris removal, to the extent such debris removal was authorized by the City. The City of Clermont hereby acknowledges that in accordance with section 305 of the Stafford Act (42 U.S.C. § 5148), the Federal Government shall not be liable for any claim based upon the exercise or performance of or the failure to exercise or perform a discretionary function or duty on the part of a Federal agency or an employee of the Federal Government in carrying out the provisions of the Act. C. To avoid duplication of benefits pursuant to section 312 of the Stafford Act (42 U.S.C. 5155), the City of Clermont will obtain from homeowners' associations or private property owners information and documentation relating to any applicable insurance coverage for such debris removal, and any proceeds and settlements and provide this to the Florida Division of Emergency Management. D. The Mayor or the City Manager is hereby authorized to execute the private property debris removal pre -approval agreement necessary to implement this Resolution. Section 4. The City Manager is authorized to on behalf of the City and in conjunction with Lake County seek all necessary and available assistance from the Federal Emergency Management Agency. Section 5. This Resolution shall become effective immediately upon its execution (; CLE ' NT CITY OF CLERMONT Ch- RESOLUTION NO.2022-035R DONE AND RESOLVED by the Mayor of the City Council of the City of Clermont, Lake County, Florida, this 2r day of September, 2022. CITY OF CLERMONT Tim Murry, Mayor ATTEST: Tracy Ackroyd Howe, MMC City Clerk Approved as to Form and Legality: Daniel F. Mantzaris, City Attorney PRIVATE CONTRACTORMORCE ACCOUNT ROE No. DEBRIS REMOVAL/DEMOLITION Florida 2022 [Kings Ridge Community Association: 1900 Kings Ridge Blvd. Address lermont, Florida 34711 Tax ID Block/Lot: r� Federal/Florida/Tribal Landmark IY/N]: ,� v Ownership Interest and Grant of Right of Ent for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address) Kin s R!qRe Community Asst., or X The authorized agent of the Property Owner. K cA - Dou las Melza rd. HOA President The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obli ,'ated: No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Monev Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Paget of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) Assured Partners _ to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # Policy # ) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowled2 m ent of Prohibition on Fraud. Intentional Misstatements and Covenat to Pay The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signatures) and Witnesses Pro Pern Owner s l or Authorized Agent and Mort{7aie/Lien Holder(s) For the considerations and purposes set forth herein, Uwe hereby set my/our hand(s) and seal(s) this Z,1 day Witness 1 Property Owner/Authorized Agent RVI Baraho Manager Si n Witness 2 - 0 KRCA - Dou las Melzard HOA President LJ"in Correa, Asst. Manager Print Property Owner(s)/Authorized Agent Current Address and Telellhone No.: 3524 Westerham Drive / CELL : M 810 - 5182 rivary nt . tatPmPnt• a rnruaMv ..,.,a.:� Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. If Demolition, Lien Holder Sign_ Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Sussex Neighborhood HOA - Kings Ridge - Clermont, FL Tax ID Block/Lot: Federal/Florida/Tribal Landmark [Y/N]: _ Ownershig Interest and Grant of Right of Entry for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address)_ , , or X The authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated, No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work .has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, ifthe Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. ' Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an obligation to' file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Pagel of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) , to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # Policy #_ ) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledgment of Prohibition on Fraud. Intentional Misstatements and. Covenat to Pax The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than. five years, or both, as provided under 18, USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Sig,, Lture s and Witnesses Propene Owner(s) or Authorized Agent and Mortgage/Lien Holder(s) For the considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this 30 �f September n m 1) — Witness Witness Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. Property O ne uthorized Agent Sign Vd11ia ia, sident Sussex {Kings Ridge) Print Property Owner(s)/Authorized Agent Current Address and Telephone No.: 4158 Capland Ave. Clermont, FL 34711 352-708-6129 If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: day Page 2 of 2 ok t.- rr- W P', ( ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax IDBlocIdLot: Federal/Florida/Tribal Landmark [Y/NJ: _ Ownership Interest and Grant of Ri ht of Entry for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address) 14 1rar The authorized agent of the Property Owner. The Property Owners)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM 3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated-, No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Page 1 of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # , Policy # } to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledg Ment of Prohibition on Fraud, Intentional Misstatements and Covenat to Pay The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Sip-nature(s) and Witnesses Property Owners or Authorized Agent and MoMlage/Lien Holder s� For the considerations and purposes set forth herein, Uwe hereby set my/our hand(s) and seal(s) this day Z%f )ni,) Witness 1 Witness 2 Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to Perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. Property Owner/Authorized Agent Sig Print Prope wner(s Authorized Agent Current Addre s ands -Telephone o. / I if If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: _ Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 Z�Uplkv lW10 ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVALIDEMOLITION Florida 2022 Address: Tax ID Block/Lot: Federal/Florida/Tribal Landmark JY/NJ: 0 ership Interest and Grant of Right of Ent for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she arelis (check): ' The owner(s) with authority to grant access to the property at (address) ` r The authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated; No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Govemments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Pagel of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # _ . Policy #_ _) to Lake County identified herein and/or to the State of Florida If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowled ,ment of Prohibition on Fraud. Intentional Misstatements and Covenat to Pav The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signature(s) and Witnesses Pro e Owners or Authorized Agent and Mortgage/Lien Holder(s) For the considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this - day Witness 1 Property Owner/Authorized Agent Sign Witness Print Property Owner(s)/Authorized Agent Current Address and Telephone No.:6 rrvacy :.ct . taiement; a Property c iwn, h1i f y s Owner's Authorized Agent acknowledges) that information submitted will be shared with other government agencies, federal and non-federal, and If Demolition, Lien Holder contractors, their subcontractors and employees Sign but solely for purposes of disaster relief - management to meet the objectives of this Right- Print Mortgage Holder/Authorized--Agent Current of -Entry. This form is signed to allow access to Address and Telephone No.: perform debris removal and/or demolition - - - operations on the above -mentioned property, to authorize the release of insurance policy/claim Sign information and to notify any lien -holder of — - demolition. - J Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: __ Page 2 of 2 ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: Federal/Florida/Tribal Landmark [Y/NJ: Ownership Interest and Grant of Right of Enti-Y for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): f2 �M i11�%TD Ni S R J p be" The owner(s) with authority to grant access to the property at (address) , or The authorized agent of the Property Owner. The Property Owners)/agent authorize(s) the City of Clennont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors' to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated: No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Page 1 of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) _ to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # Policy # _) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledment of Prohibition on Fraud, Intentional Misstatements and Covent to Pav The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signature(s) and Witnesses Property Owner(s) or Authorized Agent and Mortgage/Lien Holder(s) For the considerations and purposes set forth herein, Uwe hereby set my/our hand(s) and seal(s) this day Witness 1 _ _ Property Owner/Authorized Agent Witness 2 nvacyc t c: i emen! --TFe-roperty caner Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. Sign Print Property Owner(s)/Authorized Agent Current Address and Telephone No.: i3 5 X % 0 a - 61,51 4311 ok snav AVE, f� iGyernO FG 3 %1 If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 Fero : Tom Guequierre guequiet@gmail.com Subject: Huntington FEMA Docs mate: Sep 30, 2022 at 2:30:53 PM To: Doug Melzard ne,.,,-hiP52@ao1.co Hi Doug, FEMA Document (1 & 2) signed by Huntington President Dave Stailey attached. Please confirm you 1 the "witness signature" let me know or feel free to sign. Thanks - Tom ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: FederaMorida/Tribat Landmark [YIN]: _ Ownership Interest and Grant of Right of Entrti for Debris Removal or Demolitio The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address) X The authorized agent of the Property Owner. )C p A.W%t &W�7—I A(yA,;MUnit Al The Property Owners)/agent authorize(s) the City of Clermont, the State of Florida,and tS their respective agents, successors and assigns, contractors and subcontractors (collectively, the Contractors") to have the right of access and to enter the property above specified for purposes of pi removal as it is a public health and safety threat to the general public resulting from the declared major d Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. - Perform demolition activities on the Property to the extent that such demolition is in the public interest pu 44 CFR Section 206.244. G_ovemment Not Obligated: No Expense Except For Insurance Proceed The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contr. debris removal. Governments/Contractors will access the property under this ROE if the work has 1 necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be char conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or co other sources for debris removal or demolition, the Property Owner's obligation is set out in the sectioi "Avoidance of Duplication of Benefits...." i,nvarnmant Tnfl,-mn;APA wnfl A'alri Marmiaee For the considerations and purposes set forth herein, Uwe hereby set my/our hand(s) and seal(s) t) of Witness 1 _ Property Owner/Authorized Agent Witness 2 Sign Print Property Owners)/Authorized Agent Current Address and Telephone No.: $11 3Q17. a;' G'd uA Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other goverment agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. If Demolition, Lien Holder Sign - - — Print Mortgage Holder/Authorized Agent Address and Telephone No.: Sign Print: Othw Lien-Holder/Authorized Aget Current Address and Telephone No.: ROE No. PRIVATE CONTRACTORIFORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: FederaWlorida/Tribal Landmark [Y/N]: — Ownershi.p Interest and Grant of Right of Ent ry for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): I ✓ The owner(s) with authority to grant access to the property at (address) r �l � 1el � s The authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated; No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of -any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7359. Pagel of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # _ Policy # _ ) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledament of Prohibition on Fraud Intentional Misstatements and Covenat to PaN The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signature(s) and Witnesses Property Owners or Authorized Agent and Mort a e/Lien Holder(s) For the considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this day „f 17m) Witness 1 � Property Owner/Authorized Agent Witness 2 ' Sign Zz� tDi got 4 0 1LI[ INr_0N' _ Print Property Owners)/Authorized Agent Current Address and Telephone No.: 3 U - a V`3 ' gav, 7 Privacy - ct tatement: iTe Property ( )wner: -� Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and If Demolition, Lien Holder contractors, their subcontractors and employees Sign _ but solely for purposes of disaster relief management to meet the objectives of this Right- Print Mortgage Holder/Authorized Agent Current of -Entry. This form is signed to allow access to Address and Telephone No.: perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim Sign information and to notify any lien -holder of demolition. Paint: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 �i'raMV0 'IV A-S <J ROE No. PRIVATE CONTRACTORIFORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: Federal/Florida/Tribal Landmark [Y/N]: _ Ownershi Interest and Grant of Right of Entry for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check); The owner(s) with authority to grant access to the property at (address) I�1�, or `L,--he authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206,244. Government Not Obligated: No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits.. ,." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Govemments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Pagel of 2 Release of Insurance Infon-nation If insured, the Property Owner/agent authorizes its insurer, (Company) to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # . Policy # __ ) to Lake County identified herein and/or to the State of Florida. if this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledgment of Prohibition on Fraud. Intentional Misstatements and Covenat to Pa The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties. imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signature(s) and Witnesses Property Owners or Authorized Agent and Mort are/Lien Holder s For the considerations and purposes set forth herein, J/we hereby set my/our hand(s) and seal(s) this day Witness 1 _, ;Property Owner/Authorized Agent Witness 2Sign t Print lropzeldy Owner(s)/ ithorized Agent,f� V Current Address and Telephone No. I&R ��t' 30 ' Privacy Act • tatement: I lie PropertyOwner/ Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tag ID Block/Lot: Federal/Florida/Tribal Landmark JY/NJ: Ownership Interest and Grant of Right of En,, i-v for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address) ✓. �r The authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Oblh4ated- No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits..." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Monev Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Pagel of 2 Of A Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # , Policy # ) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowled�unment of Prohibition on Fraud. Intentional Misstatements and Covenat to Pav The Property Owner/agent understands that an� individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signatures and Witnesses Prol)erq Owners s) or Authorized Agent and Mortgage/Lien Holderis i For considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this c3o 0Z day ,.f Witness 1 ro .�� ---- - rty Owned /A uthorized Agent Si Witness 2 g Print Property O ner(s)/Authorized Agent Current Address and Telephone No.:X—�— �,/o ��`� 47— Owner's Authorized Agent aelmowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. If Demolition, Lien Holder Sign_ Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: FederalMorida/Tribal Landmark [Y/N]: _ Ownership Interest and Grant of Right of Enta for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she arelis (check): The owner(s) with authority to grant access to the property at (address) z ,� , , or _ The authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated: No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of oval Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Pagel of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) , to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # _, Policy # to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledgment of Prohibition on fraucL Intentional Misstatements and Covenat to Pa\ The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. SiLmature(s) and Witnesses P1gLer< , Owner[ s i or Authorized Agent and Mort,_tale/Lien Holder! s f For the considerations and purposes set forth herein, Uwe hereby set my/our hand(s) and seal(s) this 30day nfSe•104'rA,6br,- one,) Witness 1> Witness 2 L i�nvacy act statement: i tie rroperry t!wner. Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. Property Owner/ Authorized Agent Sign Print Property Owner(s)/Authorized Agent Current Address and Telephone No.: If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: _ Page 2 of 2 %S',*.i, ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tag ID Block/Lot: FederaUFloridafMbal Landmark [YIN]: Ownership Interest and Grant of RhAt of Ent n for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address)_ .` , or i The authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Govemments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated_ No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of --Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Govemments/Contractors. However, ifthe Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Govemments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Monev Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778: (352) 241-7358. Page 1 of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # _ Policy # ) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledgment of Prolvbition on Fraud. Intentional Misstatements and Covenat to Pay The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Si lature(s) and Witnesses Pro e Owner(s) or Authorized Agent and Mortt,age/Lien Holders) For the considerations and purposes set forth herein, Uwe hereby set my/our hand(s) and seal(s) this day „f Im1 Witness I Property Owner/Authorized Agent P"t Witness 2 ' _ `. ��f ' Sign ,,99 Print Property Owne'r(s)/Authorized Agent Current Address and Telephone No.: S_ S 356c-7 L 1 j,+of �S c� Jm lam- u' 0 e rewnt_ rl rivacy Act Statement: }e roperty t)caner Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and If Demolition, Lien Holder contractors, their subcontractors and employees Sign_ _ but solely for purposes of disaster relief management to meet the objectives of this Right- Print Mortgage Holder/Authorized Agent Current of -Entry. This form is signed to allow access to Address and Telephone No.: perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim Sign information and to notify any lien -holder of demolition. Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 ROE No. PRIVATE CONTRACTORIFORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: FederaUFloridaffdbal Landmark [Y/N]: _ Ownership Interest and Grant of Ri{,,,ht of Entr v for Debris Removal or Demolition Activities_ The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address)�/v , or The authorized agent of the Property Owner. NgS�GcfP /�g i��i ��- The Property Owners)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obli ated No Fx ense Excc t For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Page l of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # , Policy # ) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledgment of Prohibition on Fraud Intentional Misstatements and Covenat to Pa,: The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signature(s) and Witnesses PropertyOwner(s) or Authorized Agent and Mortgage/Lien Holders} For the considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this ,JA day e%f "'Wbpr 20 2 , , Witness 1 r Qr _/ n ,r Property Owner/Authorized Agent Witness 2 - > 4!>� Ynvacy AC1 �tatiemenL: i aye rroperi s )wneri Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. Sign Print Property Owner(s)/AVborized Agent Current Addre and Telephone No.:_3S2 — p123 - c2'I — If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 ROE, No, 111210':1'I F t t)'V'1'Ii.A4'i't)WF[.'Ili('F. M ("OUNI 01.I IS, HFINit)'VAI,11>o N1t)1.1'1'It)ti Flovidri 022 I, a% ID Bloch/Lot: t'raleral.tlost idasfIribal l.antimurk FY/NI: L�« .._ tit+_+ t,t°rsrti Interest and Grant of Ri6j t otT__n_t1y_ for�i�ebris l emo� a -fir 9 )fin'+�lliti+3 Mies flue ual�i• .-,;!.itch itereb\ a:enitle" lhe\ lle'shc at' is (;he';{.! .T`P — Ar-77" � t tic ieWllel�l�l l+llh illltllltl'It\ LU Ll'ilalt :Kee�ti to-� till' lClulxrl+' :11 r%rel�frr�•:,C Mme"fs. � (��C I file authorized agent of ilic ['reel+cat\ 1 )wne•a- 1? 1 4.Y3 sa±arl a#+� i tie Pretete rt\ (hvnerts r ae.ent aulhoriietsl the C 6 ear t 'lennont. the State „f I le,ridu, 1.+"^arid of America. tit;atrs enW ihelC reSjteatl�c aeena.. ouccts:�Yr< and assigns. contra ttOrti and +uhl'eeTtlra0N•iti (+.<'11-L1h,tl:. iliE tJining debris t',intrlanr."Z to ha\c the right of acces. and to enter the property above stxcified t"r hl,rlx+`.,' ;,l aswiatg d da' rmt�vltl as a t> a public health and .afet% threat to the general public resuiting from file: clee-le+till eiid'or di ts:er IFiorida s I-re.raical Storm lan, tAl-3584-FL). nj\ ernments t ontractors will perform the following work: Remo\ e dehri. from the Propett%. lc Per?ornt demolition activities on the Proper, to the extent that such demolition is in the public into G-= s hrsua:�t t.+ I it 44 t f R Section 206.244. Government Not Obli ated-, No Ex ense Exce t For Insurance Proceeds i he Property ()+cneriagent understands that thin Right -Of -Entry does obligate the governments Chas eon `to it`�i'r^ 4 lchri: removal. C;overnments%t"ontractors will access the ro rtunder this ROE if thew [ram �harg.d fist die +v, rk pecessart in accordance with Federal. State- ejr local regulations. ChC Propl rt} t)wnertsi will nee .eanduestrd b+ Ciuvernments'Contracte irs. I luwever. ifthe Propene Owner receives insurance proceedz, or ee>atvpen:ati;tn irc�=:5 other sources for debris removal or demolition_ the I'roprrtx Owner's obligation i� .el ,lug in the seetiOn 'tx:lav\. entilled A+aidance elf'Duplication of Benefit..-.. Government Indemnified and Held I larmless i he Propem Owner(sY agent agreets► to indemnify and hold harmless the Governments/Contractltrs for an) damage of tire\ ersonal property and fixtures situated thereon. ov for bodily whatsoever to the above described pmpert} ear lu ptnll;tti er death to persons on the property .end hereby releases. discharges and +v aives any and all actions. either legal or Qyuitablc. :.hick the Proper[} Owner(s) hasfhave. or ever might or may have. by reason of anv action t:t co bti ( io+ernmentseConlractcors pursuant to this Night of Entry. A%oidancc'Ut•I)U licationol►B file annsu etSrance Reporting fbovet•aglmo araile. al MableProRteedveditbtrt;-'Lt�t i'r, r1,t.rt. ()%+nee a€ent has an obligation tuldcliwad, and ack ov%ledges that 1•eceipt of compensation or reimbursement for performance c)�'thc atlotirnentiell�tri at:tl%rjll:: 1t'us/pa :.lily ititurce. rncludino Small Business ,Administration. pnvate insurance. an indt+iduill alki tamttgalnt progmaj or trig+ +tiler public or private assistance program could constitute a duplication of bc:ndits t➢rvhlblted b} federal lief+. If the 11r opixty ()evncr argent recei-ve., am compensation from any source for ticbr►s it:mOval t+it this 1'1t�pest} . the Properr} tyr �wIcl-'a""crlt ccill relxan it to City Manager of the Cit, of Clermont- 685 Wcsl Moliivuse 5trc t, C:1ermUn► Florida 12778. (352) 241- 7 69. Page 11 of I El Release of insurance Information It iuNkirO. the tiropert) t Iwneriagena authorizes its insurer, tt'nnipau,) to relea _ __-- _ _ se lt,titi+natit+u rt atili� to col erage and paNinents titr debris removal and/or demolition activities tC l�" ' frutidv ,, I to take Clitinty identified herein an&or to the Stale L,f Florida, It this section i� leli blank, the undersigned certifies and covcilmits. im ltchaif ,1f the properly .�-ancr L,r en?itV in cfa11001 t-1f 111t. I,i*ivate pr(,#pc:rty that if does not have insurance ciiv/rriwt.' r tittaL) 1,i ilctlrr; lemovrll Ac knowlec!_ 111CIII o Il1'1111t1+1tlotl 4111 I'I'7111t� �t7tt:flti4ellill lVlts`,t�ttcments grid cuvenat to .Pao _ _. _ misstates all) tael in Ilie Property O%Al►t'1lJ,:-cjv mith iUtik 111,11 all lltdividlral �'tlfi IrYilllrylcittl, t,r b�7�I�UI1} c'olin Ction e\iiti 111t, .li'!i'+'7ite"Apt 11111, K. •,11111cc; 1,' pviillltic". till$ti"r '.11llt :IIbt1 f4da'ftll I:+Lv- liiCllldi►ig at it penalties. • 1 i:luti:t fR f?�L: l�{99- lit tfie L;dLPat that ;rue it' cm i;t1tN'1�tHliitt7lt tt'l not ilt'i1 111,.111 ►1LL lt:lr•,, ,al faith. , , pi-to,1Idt' Uit\ of Inl�±l:1te1111'nt. Itiltiil IIfL",t iti:llle ti "i +i141i•.,I+tit tOlIC1111,41 i'•l 1,1,1cil Ilci to lIpo/fir file derlial (it +teiWrIcTb -'ii to fd��E +t� Zt Cieltilollt. Ille 1illdt•r�i:.m%t i-11 11%.11 all 14 Ow L.1111h itlilt (,,llt(i,l.`, ttit' firl •=lti pr(lperty grees Ocrlllont I'm np► atn.l :19t . ,mot ttt Ichti, icim,vitt iiuimoi Ilw_'renilder- tit rtl noturcti) and WttnesScs f'rc► �:rtv (i��,•tte s tIr i�tttiltlriii:dl � �t°tlt atld Mrart�=-�t�t/Lien f ialde s 'aft)iIf 1'itlllclls)andscal(s)'this �{� day' I -or the ctlnsidcrai' of 4s loaf I'll1•llosi � � '1 fL 'III tlerl tit, llSi`l' hl lt} y set my ,/.� I'ratlaerty (tvw•nt:,r/A uthorizcd Agc,a1 Witness Signs lam' Wltncss t'rlV3CL A.'5 MalClllUllt. i "w a - ------ f]u nc is Authori/_ed Agent acknow ledge(s) that infcirmation submitted mill he shared with other *t v ernment agencies. federal and non-federal. and contractors. their subcontractors and emplo}ee. but soiek lhr purposes oi'disaster relief manavement to meet the obiectives ofthis Right- o1_Lntn . Fhis form is signed to allow actress to perfiorm debris removal and/or demolition operations on the abort; -mentioned property. to) authorize the release of insurance policy claim information and to notifj any lien -holder (-it' demolition. Print Vropert) 0vvneritO ALttzuri7ed \genl Current Addre s and Tclephonc NO.: `M7$. EV4- _ t_1' If Demolition, lien Moldier Sign Print Mortgage llolder/Authorized :\cent Ctincni Address and Telephone No.: Print: Other Lien I lolderlAuthot'ized Agent Current Address andTelephone'No.: _ r !� IrH1/ � I F: [ 11ti! !t 7l I ills tuft[ t .►i [ its y'-t' Moir Aw IIHIS ttl ►t11► ►r !rl ► ILl110-s 1Flnrlda ]a,: Addrn- t.% 11) ILtI}rVl.Srl: edertj 110rWLaI"bA t aaJer A I N1: stars jffwgr tbeftrtr? "otrK%ron nt-r wam- ,+►tm•r ToromftvtrI -rsh awdwrrr} Lo Vara w-Wst to It+t pru rs+ The atafor od beret of et* hvf*M [}watt rfik— for t�*Ke*1! Amw ()%mgsj*" "hanretsi tee Cat) of Ckr,,,+w ste tinsr of I Meld+ wrd tot tFrrited States relrsetnelr e.ir rr.pwms agwal, sutce+wn -4 asws-. tr+rrt: -ton arrd ��'+ [tat[i+�reh- the i-irrgra�lirn'► In hale Llrr ri��, of ane■+ anJ u� rnrer rhr rrapert}' abaare ,ptcrRN far porrclsr+ of perfwtairrg dcbr*s res-►atir! a► it a. aptt6tx hold+ ■r.! utct► ib at en the prnff*l p�lic awkd t JAM ehc dociarrd rna�ut dit.eeclr lfloflda'� TrWkal b'snrm !art 061.349i-I 14 Carstrrwse+rrL['ne+rra:ron will prytvrm the irwuftisyl "-fi m ow debris from tot ft"It peerh]eeq divasoteioe apivain m the Nora y to etas c%hW this ws Is dtmn114-n is in the r't"it in401ml PanuaM to Till /i CFR 5adw 2W I", Govemmt`nt Not DMiested: No "rsenm Except For Insutance Irv-xeCds Iris Itopertr Ltwe rt +►,w wrkrcrarag% dew t}aa Rl-of.I.:wy doeK "uhlipw the fio%,et merdLVa etrtreto" to pert wns Ormf reLraral. [inrerrtrursls['nrttfa[ftXr mil +toes$ the pn>Sserty un,kt this R04: it the wnrk hm Ism kesermin d rucnw v to aa[tWaNKC rflh fnkRel. Steve, or"rcpsla ww& 1U Pwperty 0,A?KrtW +•ill rwA tv chwktcd for the *ark ccmd►rted by uarxxm+trts+�C�rectaa. titrs.rnr, tf rile �y't7,st►er r>,«uri+�e iseLalrareCc prncced+ nr ctsrnpernartian darts pellet uaarrs rer dtttrrL mmvn al at dmmlititm the PmrmY Lhrner's 41111Vi1im is eel NA rn the section bclem, cteliUed 'A►»kinw o[aupispetion of l rst... �Ir15 t1 The Prty nr 0%nrnis)7Ftrt 470t+ Sj to I Wanra S am! !said hwmku the (40M- 4Men <t/C0Atrs UW$ fray ally Qare W tat any 4Pr s►he k%mer to the above dmrlkd promin or to Frrumw prelpeftsr Aral f mu►ns sitlaatcll t1wTom. at fw {+trebly ir4L ar drath Lo p:r>rxw nn the prt>flcrsy• and hlrrt) tek-arw%. d►salsssm and wakt% rosy sled all rttinns, tither kyta[ tx tyuitaFelc rfbch tAe r'roprYty U+■e:;rtli hRslsnl~ or c+tr mutt crr retry Farr. by t vmm Of acm 991 asL tAcn by (ioarnsrncrWA ne412Ltern purummi to tfsit P.06 of F.nrtp. Avoldanice of [At licalion of Bencfits: Re $min Debris Rema►.a1 Moncv Rccci►ed Prcrjerl) [Anil +[;ere hss an r+bliSaWn 111 flit an im4evxe cwm of ea► c it available w',1km! kJ$ *'led w1norakdgm uw nui srf cam ettt� gy m' i t+cs a�c01 s.'ii►daft Frtwn an, trerLxatarea or ft'm tlttletgent for prrf►srm,xmc Ot tht atemmetlliaoed xcnrce including Small (3tLsir'm Admin1dra e& prime inrurrncC. an indiriduai rind family gear*$ C+brr a ry urn wllk ur prisatr tsssittan[r Tau [r roc I'r QN prv1Mn COW canalttlrc a duplscaason of bcrseiits prohibited by fc*icral h► aPe+'si' net: a�xte rccriY+cs any Mnspr:ILif kws frLtm any s mme for Ajc •"$ rcmu►al on this prtoelty , fda327 [3+•mrNagsrnt veil! repurc �t w iuy M&w9rr of tilt 01Y of t'lrrrrwM 635 West Monsrasc 5trexl. Clrrtsson4 F3arida 32378.(35.) PUC l of 2 R -,r - - ati .— - — . Release ol'Insurmicc Information If +nwrod. the Property Ue►ner metal nuil urixes its insurer. (Company) _ , to relea--w infurmxtion rrlaring to CO%V tr and payments fear debris rrmnval and/or dernolition activities (Claim Poli.y # 1 to Lake County identified hercla antUor to the State of florid& If this se+ctinn is left blank, the undemigned certifies and em eraents on behalf' of the pnipen), owner or entity in control of the Private Prope--ty that it does not have insurance co. eragc related to dcbrii rrmoval_ Acknowleeit gent «f Prohibition on Fraud, Intentional Misstatements and coIIIcnat io I'nv the PrcWrty O%ncr,-sjI underxtarufs that an individual who fraudulently or willfully misstaics any fact in connectiar uith this Wcrment ntav be sutyec.t to penalties under state avid federal law, including civil penalties. imlwisonment for nor more than five vicars, ►I both. & Provided under 19 USC I Uo I . In the event that due to any mitiatwemcnt. miwPrrscntation or omission contained or related hereto and/or the denial of reimbursrraemt tie the City- of Ckmwnt. Or undcrsijpW on behalf of the entity that controls the private property agrees to reimburse the City of Clersnmt fnr any and ail cast of debris removal incurred hcreumicr. Sioalure s and Witnesses Pro yrty Owne s or Authnri�e.•d Agent ant! Mart ►age/Ijen I Ivldes I or the cdnsidrratinns and Tr" Fort hei onsiZ�! y purposes sct forth herein. Vwc hcrcb►- set rnyrour hands) and scaI(s) this 34 day Wilness I - PrnperiY (),AncrYAuthori;I Agent Witness 2 Sign Yrr% aCy Ac crner! : p [)v►ncr's Authorized Agent uckn�fl�g Ys) thatt inrorntatinn submitted will be shared K i[h whey ltOWnImcnl agencies. reefs -Till and non-fidrrnl. and r"nVICto►st their sti ��rrtrartors and cmPio)ces but solely for puToscs of disauler relief m ge"letll to meet the objectives orthis Right. an beery, This form is sip;need to allow scares to perform debris removal and/or iletttolili(}n ONrations on der abo►Ve-me-nlionrd pri}dim. to autbnriu the rrlcatse of insurance Policy!clairn irifrrrmalion and to notify an) licn•Iwldef of *11101i[ion. rntarl'ropely OuncrOYAuthonzed Agent rrcnt Addriss and Telephone No.: 442111 1-�q+o� ,2 t — �' If Dentulition, I.ic.-n Helder Sign- -- Print Al?ongage I lolderlAuthoriudAgenl {`itrren[ riildtCas attd Telephone No.: ~ Sign i'rint; U[hrr i.it n Iloldcr/Auihorized Agent Unrrunt address and Telephone No.: Page 2 of 2 k'. Karmin Teets From: James Maiworm Sent: Monday, October 3, 2022 9:59 AM To: Stoney Brunson; Brian Camp; Elke Fischer; Angela Banas; Karmin Teets Subject: RE: debris removal 10-4 James Maiworm Assistant Director Public Services 3335 Hancock Road., Clermont, FL 34711 � " NT Tel 352-241-0178 1 Fax 352-241-0542 (.+ 1 imaiworm(cDclermontfl.org .v of Chi www.clermontfl.qov Our mission: To preserve and enhance the quality of life for the Clermont community by providing exceptional services From: Stoney Brunson <SBrunson@clermontfl.org> Sent: Monday, October 3, 2022 9:00 AM To: James Maiworm <jmaiworm@clermontfl.org>; Brian Camp <bcamp@clermontfl.org>; Elke Fischer <efischer@clermontfl.org>; Angela Banas <abanas@clermontfl.org>; Karmin Teets <kteets@clermontfl.org> Subject: FW: debris removal Jim, Please see below so we don't go through this area. Stoney Brunson Public Services Director f 400 12th Street., Clermont, FL 34711 1' Tel 352-394-7177 1 Fax 352-394-8776 CLEF 1 sbrunson aclermontfl.or choim Of Cha-,T,.DMM www.clermontfl. ov Our mission: To preserve and enhance the quality of life for the Clermont community by providing exceptional services. From: Brian Bulthuis <bbulthuis@clermontfl.ore> Sent: Saturday, October 01, 2022 10:29 PM To: Stoney Brunson < IBrunson , clermontfl.or> Subject: Fwd: debris removal Brian Bulthuis Begin forwarded message: From: James Purvis <jimpurvisC?aol.com> Date: October 1, 2022 at 8:21:04 PM EDT To: Brian Bulthuis <bbulthuis clermontfl.or > Cc: rinksp(a),aol.com, reedss0629 aol.com, jthowell@,yahoo.com, mcctry@yahoo.com, jaguartoys(a,aol.com, ttorres a)vistacamfl.com Subject: debris removal Reply -To: James Purvis <jimpurvis(a,aol.com> Brian; Late today I learned that my Wellington at Kings Ridge HOA has (unanimously) decided to "go it alone" concerning storm debris removal from our neighborhood. This, against my strong objection (but even the president only has one vote). In this case - I had but one voice as no formal vote was taken. That said: Please advise Stoney (I wanted this to come from you - vs me) that he can now free up his limited assets to help others in the city vs. Wellington. Again - I sincerely thank both you and Stoney for your direct involvement in finding ways to assist our community in every possible way. Also - please destroy the FEMA form I executed Friday afternoon. I know for a fact the Master Association is VERY appreciative of the city's efforts to assist them. this coming week. Sincerely, Jim Purvis _ Pres Wellington at Kings Ridge, Inc. James Purvis iimpurvis(a-)-aol.com i ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: Federal/Florida/Tribal Landmark Iv/NI: Ownership Interest and Grant of Right of Enta for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address) moo Legendary Blvd, Clermont FL 34711 a or x The authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated; No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Govemments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Mone Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. zy el �' Pagel of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) , to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # , Policy # ) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowled rment of Prohibition on Fraud, Intentional Misstatements and Covenat to Pav The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. SiL,nature(s) and Witnesses Proiv Owners) or Authorize- d Agent and Mort�,age/Lien Holder(s) For the considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this rtvacy ct tatement: ie ropert� wne,, - Owner's Authorized Agent acknowledge(s) that I information submitted will be shared with other I government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. N Notary Public State of Florida Robbin N Arsenault My Commission GG 323665 Expires 05/1512023 Proper W,4cr44v4kori_zeA Agent L'yesj 1�t� c RES _ Print Property Owner(s)/Authorized Agent Current Address and Telephone No.: If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: day Page 2 of 2 ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID BlocldLot: Federal/Florida/Tribal Landmark [YIN]: Ownersbip Interest and Grant of Right of E 9U for Debris Removal or Demolition Activities gThh rsigned hereby certifies they/he/she are/is (check): e owner(s) with authority to grant access to the property at (address , or e authorized agent of the Property Owner. The Property Owners)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perfonn demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated: No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal, Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, ifthe Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The .Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owrier(s) has/have, or ever night or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. 'A Page 1 oft Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) , to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # , Policy # ` ( to hake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowled Unent of Prohibition on Fraud Intentional Misstatements and Covenat to Pav The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Si natures and Witnesses Property Owners or Authorized Agent and Mortgage/Lien Holder(s) For the considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this day „f onT) Witness 1 _ Property Owner/Authorized Agent Witness 2 _ Sign__ Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. Print Property Owner(s)/Authorized Agent Crrent Address and Telephone No.: oil If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 ROE No. ' PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: FederalMorida/Tribal Landmark [Y/NJ: A/ Ownership Interest and Grant of RiLht of Entr- for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address) or The authorized agent of the Property Owner. The Property Owner(s)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not Obligated; No Expense Except For Insurance Proceeds The Property Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: teporting Debris Removal Money Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Pagel of 2 Release of Insurance Information If insured, the Property Owner/agent authorizes its insurer, (Company) _ , to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # . Policy # ) to Lake County identified herein and/or to the State of Florida. If this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledzment of Prohibition on Fraud, Intentional Misstatements and Covenat to Pay The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signature(s) and Witnesses Property Owners or Authorized Agent and Mortgage/Lien Holder(s'f For the considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this r%f 5 �� s cati► PAW,, 2922 .;Of day Witness Property Owner/Authorized Agent kLI L.4.-S Witness Privacy Act Sfffement: The PropertY _ wnerr Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. Sign `} �"- H2OA P2►ate V1NCW7` m!ey-ke-e" --- Print Property Owner(s)/Authorized Agent Current Address and Telephone No.: +{SfoR BRn�u s-rriL' Cr..CrLr+1v+�(� F� 3'�► ► t fo!�f�v� �-T� — `]toss If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2 - -- ----] ROE No. i PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION MOLITION 1 Florida 2022 Address: Tax Ill Block/Lot: Vederat/F'iorida/Tribal landmark lY/Nl: Ownershi Interest and Grant of Ri,1it of Entr r for Debris Removal or Demolition Activiti 1 lie undersigned hereby certifies they/he/she are/is (check): �.1� l The owners) with authority to grant access to the property at (address) KoA Is 09- MAn+ The authorized agent of the Property Owner. -- _ - _, or The Property Owners)/agent authorize(s) the City of Clermont, the State of Florida, and tite United States of America, their respective agents. successors and assigns, contractors and subcontractors (collectively, the "Governments/ Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's 1 topical Storm fan. FM-3584-1,T). (-'nverrrments/('oruractors will perform the lollowing work: Remove debris front tliv Property Perform demolition activitie.s on the Properly to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not: Obligated; No Ex ense Exce pt For Insurance Proceeds 7'he frr+pert; Owner/agent understands that this Right -of -Entry does not obligate the Governments/Contractors to perfi�rnn debris removal. Governments/Contractors will access the property under this ROE it' (tie work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. I toNvever, i fthe Property )i� net receives insurance proceeds or compensation fretrn other sources for debris removal or demolition, the Property Owner's obligation is set out in file section below, entitled "Avoidance of Duplication ol' fenefits—,- Government Indemnified and Held Harmless The Property ()wne.r(s)!aLent agrees) to indemnity and hold harmless the Governments/Contractors for any damage of any type whatsuever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(S) has/have, or ever might or may have, by rea on of any action taken by Gotarmnents/Contractors pursuant to this Right of E;ntrv. Avoidance of Du lication of Benefits: Reporting Debris Removal Money Received Property Owner/agent has an nl)tigatiou to file an insurance claim if coverage is available. PropertyOwner/agent knderstands and ackno«ledgc:: that ret:eipt of compensation or reimbursement for performance of the aforementioned activities from any source. including Small Business Administration, private insurance, all individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law_ if the Property Owner/agent receites any compensation from any source for debris removal on this Property, tilew Propertti Oncr/agent will report it it)City Manager of the City of Clermont, 685 West Montrose Street, Clermont_ Florida 32779: (3521 241-7358. Page 142 tion If insured, the Property Release of Insurance InformaPropertyOwner/agent authorizes its insurer, —(Company)- H TFOIt to release information relating to coverage and payments for debris removal and/or demolition activities (Claim -- POlicti- $41A Z3 __�A'I'Y_'�) to lake County identified herein and/or to the State of Florida. if this section is left blank_ the undersigned certifies and covenants on behalf ofthe property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acl;nowled anent of Prohibition on Fraud, Intentional Misstatements and Covenat to Pa f'lie Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement ma} he subject to penalties under state and federal law, includingcivil imprisonment for nor more than five years, or both, as provided under 18 USC fool. In the events that due to l any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont. the undersigned on behalf' of the entity That controls the private property agrees to reimburse the City of Clermont for any and all cost ui debris removal incurred hereunder. Sionature(s) and Witnesses tnierty Owner s i or authorized Agent and Mort taste/Lien Holder(s) For the consideration; and purposes set forth herein. I/we hereby set my,our hand(s) and seal(s) this �-day „'' QCr�p1a.[.�r 20 Witnes Property Owner/Authorized Agent i ivacy et , faterrrcnt: to . ropert� Owner — .r Owner's Authorized Agent acknowledge(s) that iniorination submitted vvill he shared with other government agencies. lederal and nun -federal. and contractors. their subcontractors and employees but solely for purposes ot'disaster relief management to meet the 41bjectives ufthis Right of Entry. this Lorin is Signet] to allow access to Perform debris removal and/or demolition operations on the above-mc;ntioned property. to sauthorize the release of insurance t. dIcy!cla'irn information and to notify am lien -holder of demolition. Sign_ -Gvt 104 Print Property 0wner(s)/Auth0rized Agent Current Address and 1 elephone No.: Ka7 ,gy7• ?30g6 If Demolition, Iaien Holder Sign_ Print Mortgage I folder/Authorized Agent Current Address and 'Telephone No.: Sign P -int: Othzr Lien I ]older/Authorized Agent Current Address and Telephone No.: Page 2 if 2 ROE No. PRIVATE CONTRACTOR/FORCE ACCOUNT DEBRIS REMOVAL/DEMOLITION Florida 2022 Address: Tax ID Block/Lot: Federal/Florida/Tribal Landmark [YIN]. Ownership Interest and Grant of RiLht of Entry for Debris Removal or Demolition Activities The undersigned hereby certifies they/he/she are/is (check): The owner(s) with authority to grant access to the property at (address). -Aor 71— The authorized agent of the Property Owner. The Property Owners)/agent authorize(s) the City of Clermont, the State of Florida, and the United States of ,\mcrica, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governmentsr Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal a<5 it is a public health and safety threat to the general public resulting from the declared major disaster (Florida's Tropical Storm Ian, EM-3584-FL). Governments/Contractors will perform the following work: Remove debris from the Property. Perform demolition activities on the Property to the extent that such demolition is in the public interest pursuant to Title 44 CFR Section 206.244. Government Not ObILated- No Exi ense Except For Insurance Proceeds The Property Owner/agent understands that this Righr-of-Entry does not obligate the Governments/Contractors to perfonn debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Ownerrcceives insurance proceeds orcompcnsation from other sources for debris removal or demolition, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits...." Government Indemnified and Held Harmless The Property Owner(s)/agent agree(s) to indemnify and hold harmless the Governments/Contractors for any damage of any type whatsoever to the above described property or to personal property and fixtures situated thereon, or for bodily injury or death to persons on the property, and hereby releases, discharges and waives any and all actions, either legal or equitable, which the Property Owner(s) has/have, or ever might or may have, by reason of any action taken by Governments/Contractors pursuant to this Right of Entry. Avoidance of Duplication of Benefits: Reporting-, Debris Removal Mone• Received Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Ovsntevagent undcrstands and acknowlcdgcs that receipt of compensation or reimbursement for performance of the nforemcneioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to City Manager of the City of Clermont, 685 West Montrose Street, Clermont, Florida 32778; (352) 241-7358. Pagel of 2 �e�nkl C V C, Release of Insurance Information if insured, the Property Owner/agent authorizes its insurer, (Company) � Iri '.> r'/�1 U.x . to release information relating to coverage and payments for debris removal and/or demolition activities (Claim # , Policy # �'' �, I'i'G't _ ) to Lake County identified herein and/or to the State of Florida. if this section is left blank, the undersigned certifies and covenants on behalf of the property owner or entity in control of the private property that it does not have insurance coverage related to debris removal. Acknowledgment of Prohibition on Fraud, Intentional Misstatements and Covenat to Pa The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001. In the event that due to any misstatement, misrepresentation or omission contained or related hereto and/or the denial of reimbursement to the City of Clermont, the undersigned on behalf of the entity that controls the private property agrees to reimburse the City of Clermont for any and all cost of debris removal incurred hereunder. Signature(s) and Witnesses Property Owner(s) or Authorized Arent and Mo tgaLe/Lien Holder(s) For the considerations and purposes set forth herein, Uwe hereby set my/our hand(s) and seal(s) this f 16 day Witness 1 Property Owner/Authorized Agent Sign Witness 2 Print Property Owners' /Authorized Agent Current Address and Telephone No.:_ Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right - of -Entry. This form is signed to allow access to perform debris removal and/or demolition operations on the above -mentioned property, to authorize the release of insurance policy/claim information and to notify any lien -holder of demolition. If Demolition, Lien Holder Sign Print Mortgage Holder/Authorized Agent Current Address and Telephone No.: Sign Print: Other Lien Holder/Authorized Agent Current Address and Telephone No.: Page 2 of 2