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What this Permit Does:
  1. By signing this permit you allow emergency Assistance Providers to enter your property to inspect, clear, and remove household hazardous waste only, caused by the September 2020 wildfires.
  2. You agree to give up any right to sue or make a claim for damages against the Assistance Providers for any resulting damage and personal injury or death.
  3. You agree to make, or allow the Assistance Providers to make, an insurance claim to reimburse the Assistance Providers for services provided to you.
  4. You authorize your insurance carrier to provide policy and claim information to the Assistance Providers relating to your claim for the services.
*This summary is subject to the full descriptions provided below.
Grant of Right of Entry:  By signing below the property Owner or Owner’s authorized agent collectively
(“Owner”), hereby unconditionally authorizes the Assistance Providers (Douglas County, the State of
Oregon, tribal governments, the United States of America including the Federal Emergency Management
Agency (FEMA), and participating Voluntary Organizations Active in Disaster (VOAD) and their respective assigns, officers, employees, agents, volunteers, contractors, and representatives) to have the right of access and to enter in and onto the property, and all related appurtenances thereto described below for the purpose of performing work described below in “Scope of Work” at no expense to Owner. It is fully understood that this Right-of-Entry Permit (ROE) does not create any obligation on the part of the Assistance Providers to provide services. Owner understands that no work will be performed until this ROE is completed in full. If Owner is a landlord, Owner agrees that Assistance Providers will be acting as landlord’s agent for all purposes.
Time Period:  The ROE shall expire 90 days after this form is signed, unless it is cancelled sooner than that according to the terms herein. The Assistance Providers – Indemnification - Hold Harmless provisions, once signed, survive the termination of the ROE.
Scope of Work and Disclosures:  The work includes the inspection, clearing, and removal of household hazardous waste, caused by the September 2020 wildfires. By signing this ROE, Owner acknowledges that none, some, or all of the work may be performed. Owner understands and accepts that the entity performing the work will determine on a case-by-case basis what materials qualify as “household hazardous waste” to be removed from the site.
Assistance Providers - Indemnification - Hold Harmless:  The Owner acknowledges that the Assistance Providers’ decisions on whether, when, where, and how to provide disaster relief to Owner's property are discretionary functions. Additionally, the undersigned hereby indemnifies and hold harmless the Assistance Providers against any and all claims, deductibles, self-insured retentions, demands, liability, judgments, awards, fines, mechanics’ liens or other liens, labor disputes, losses, damages, expenses, personal injury, death, and charges or costs of any kind or character, including attorneys’ fees and court costs (hereinafter, collectively referred to as “Claims”), as well as any and all actions, either legal or equitable, which the undersigned has, or that might arise, of any nature whatsoever and by whomever made, or may have, by reason of or incident to any decision or action of aforesaid Assistance Providers taken or not taken in connection with entry onto the Property or to accomplish the aforementioned work. 
Duty to Apply for Insurance Benefits:  I understand that Federal law (42 U.S.C. § 5155) requires me to reimburse the Assistance Providers the cost of removing wildfire generated debris to the extent covered by any other source including FEMA, Small Business Administration, private insurance, or any other public assistance program. At the sole discretion of the Assistance Providers, Owner shall either:
(a) Make a claim against any applicable insurance policy related to the work performed by the Assistance Providers under this ROE for debris removal and reimburse the Assistance Providers within thirty (30) calendar days of receipt of any such insurance proceeds for the cost of the work performed by the Assistance Providers under this ROE for debris removal; or
(b) Assign to one or more of the Assistance Providers the right to make a claim against any applicable insurance policy and the right directly to receive payment for that claim. Owner shall provide notice of this assignment to all applicable insurers.
Release of Insurance Policy and Claim Information:  Owner acknowledges that an insurance claim has been, or will be, presented to Owner’s insurance company as a result of the declared emergency for the losses and damages occurring at the property listed below. The Owner authorizes the insurance carrier to provide policy and claim information to the Assistance Providers, or assigns.
Authority to Sign:  Owner represents and warrants that Owner has full power and authority to execute and fully perform Owner’s obligations under this ROE. If Owner is an entity, Owner also represents and warrants that Owner has such power and authority pursuant to its governing instruments, without the need for any further action, and that the person(s) executing this ROE on behalf of Owner are the duly designated agents of Owner and are authorized to do so. Owner expressly represents and warrants that fee title to the Premises is vested solely in Owner.
Property Access:  This ROE includes the right of ingress and egress on other lands of the Owner not described above, provided such ingress and egress is necessary and not otherwise conveniently available to the Assistance Providers. All tools, equipment, and other property taken upon or placed upon the property by the Assistance Providers shall remain the property of the Assistance Providers and may be removed by the Assistance Providers at any time within a reasonable period after the expiration of this ROE.
Duty of Truthfulness:  Owner understands that any individual who fraudulently or willfully misstates any fact in connection with this ROE shall be subject to a fine or imprisoned or both.
Information Sharing:  Information is collected to make it possible for the Assistance Providers, and their assigns, officers, employees, agents, volunteers, contractors and/or representatives to do the work.
Disclosure is voluntary:  However, failure to disclose the information will make it impossible for us to do the work which may delay or prevent the provision of disaster services and/or assistance.
Contact Information:
Douglas County Board of Commissioners
Douglas County Courthouse
Roseburg, OR 97470


Owner’s Contact Information: (Information To Be Kept Confidential by Assistance Providers)


Insurance Information for the Property

SECONDARY Insurance Information for the Property or other damaged items on the property:

ADDITIONAL Insurance Information for the Property or other damaged items on the property: