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File #_______

RIGHT OF ENTRY ON PRIVATE PROPERTY

GRANTED TO THE CITY OF SPRINGFIELD, MASSACHUSETTS AND OTHER AUTHORIZED PARTIES

FOR TORNADO-RELATED DISASTER ASSISTANCE TREE DEBRIS and/or DAMAGED TREE REMOVAL

Property address:___________________________________________________________________________

Owner:____________________________________________________________________________________

Age of structure/property: ___________________________________________________________________

Historical: Yes / No (circle one)

Underground storage/Utilities marked/identified: Yes / No (circle one)

Pools/SPA/Basement:_______________________________________________________________________

Environmental:_____________________________________________________________________________

Insurance Company and Policy number:________________________________________________________

Declarations page for any property insurance in place and effect on 06/01/2011: Yes / No (circle one)

Affidavit of No Insurance Attached: Yes / No (circle one)

Notarized Copy of Deed Attached : Yes / No (circle one)

1) The undersigned hereby certifies and warrants that (he/she/they) (is/are) the owner(s) of the

property described in this document, and do hereby request aid in removing tree debris and/or

damaged tree(s) to prevent further damage to (my/our) property, a dwelling unit or structure and/or

to the public at large and therefore give freely and without coercion, and the undersigned

unconditionally authorize(s) the City of Springfield, Massachusetts, its officials, employees,

contractors and subcontractors, successors and assigns, the United States of America and its assigns,

including but not limited to any Federal, State and local agencies, their employees, officials,

contractors and subcontractors (collectively referred to as the Authorized Parties), to have the

right of access and to enter in and onto the property located as identified above for the purpose of

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removing and clearing any or all tornado generated tree debris and damaged trees of whatever

nature from the above described property.

2) I/we fully understand that only tree debris and/or damaged trees in the tornado zone on non-

commercial properties are eligible for this grant and that said removal activities that exceed

$2,500.00 will not be eligible for this grant. I/we also fully understand that only non-viable trees that

are/were severely storm damaged by the June 1, 2011, tornado and pose a significant threat to the

public safety and/or an immediate threat to a structure or dwelling are eligible for this grant.

3) I/we fully understand that this right of entry is not an obligation to perform tree debris and/or

damaged tree clearance and/or removal. The owner(s) agree(s) that the City and other Authorized

Parties, and their respective employees, officials, contractors and subcontractors, and other

representatives, successors and assigns, shall in their sole discretion determine whether to

undertake, and if undertaken, to determine the extent and nature of the actions to be taken to

accomplish, the tree debris and/or damaged tree removal and clearing activities.

4) I/we fully understand that in order to determine if the City or other Authorized Parties shall

undertake to perform the tree debris and/or damaged tree clearance and/or removal the

undersigned unconditionally authorize(s) the City or other Authorized Parties to have the right of

access and to enter in and onto the property located as identified above for the purpose of

evaluating the tree debris and/or damaged tree(s) to confirm their eligibility, their location in the

tornado zone, to determine the existence of underground and/or above ground utility lines, fences,

landscaping, etc and to determine the total cost of said removal.

5) I/we fully understand that if the City or other Authorized Parties determine that tree debris and/or a

damaged tree(s) shall be removed from your property that said tree debris and/or damaged tree

removal shall include ONLY the removal of tree debris and/or damaged tree(s) to stump but will NOT

include stump grinding, mulching, top soil, loam or any final clean-up such as raking, seeding, etc. All

such activities will be the responsibility of the homeowner.

6) I/we fully understand that if the City or other Authorized Parties determine that the tree debris

and/or damaged tree(s) are eligible for removal, it will be the owners responsibility to provide

property access to the location including, but not limited to, the removal and replacement of gates,

fences, shrubbery, furniture, grills, etc. and any other obstacle preventing proper access. Further, if

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equipment is required to remove the tree debris and/or damaged trees it will be the homeowners

responsibility to restore any lawn areas damaged by said equipment and or tree removal.

7) It is the owners responsibility to mark locations on the property of any utility lines including water,

sewer, and natural gas either above ground or underground.

8) Additionally the undersigned property owner agrees to indemnify and hold harmless the City, the

United States, and any other Authorized Parties, for any damage or injury of any type whatsoever to

the above-described property or to persons or personal property and fixtures situated thereon, and

hereby releases, discharges, and waives any and all actions, either legal or equitable, which the

undersigned owner has, or ever might or may have in the future, by reason of any action taken by

the City, the United States, and/or any of the Authorized Parties, to accomplish tree debris and

damaged tree clearance and removal activities.

9) The undersigned owner(s) warrant(s) that is (has/has not) receive(d) any compensation for

performance of the debris clearance activities from any other source including the U.S. Small

Business Administration, Natural Resources Conservation Service, private insurance, individual and

family grant program or any other public assistance program. (Please attach a copy of the

declarations page for any property insurance in place and effect on June 1, 2011; if no insurance was

in effect kindly include an affidavit of no insurance).

10) In the event the City or other Authorized Parties undertake to perform tree debris and/or damaged

tree removal activities, and if the undersigned and/or any other owner of the property receive(s)

compensation from any source for debris and wreckage clearance and removal on the property, the

undersigned and any other property owner will report the same to the City, and will be responsible

to reimburse the cost of such tree debris and/or damaged tree clearance and removal activities from

such insurance proceeds.

11) The undersigned represents and warrants that (he/she/they) (has/have) full legal power and

authority to execute and fully perform the obligations under this Right of Entry without the need for

any further action, or that (he/she/they) (is/are) the duly appointed agent(s) of the owner, and that

(he/she/they) (has/have) full power and authority to execute and fully perform the obligations

under this Right of Entry without the need for further action. (please attach a notarized copy of the

deed to the property at which the services are being requested).

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For the considerations and purposes set forth herein, (I/we) hereby set (my/our) hands and seals on this ________

day of __________________, 2014.

Signed: Signed: _________________________________________ _________________________________ Property Owner or Authorized Agent Witness

Print Name:________________________________ Date signed: _____________________

Current Telephone Number: ______________________________________

Current Address: ________________________________________________________________

Signed: Signed:

_________________________________________ _________________________________

Property Owner or Authorized Agent Witness

Print Name: ________________________________ Date signed: _____________________

Current Telephone Number: _______________________________________

Current Address: _________________________________________________________________

Please return this form and supporting documentation to:

Springfield Department of Public Works Engineering Division Attn: Pat Garrity 70 Tapley Street Springfield, MA 01104 For Internal Use Only: GIS/Assessors Office Info:__________________________________________________

GPS location: Longitude:___________________ Latitude: _____________________