Right of Entry and Work Authorization
The undersigned property owner, authorized owner’s representative, or authorized lessee (“Owner”) hereby grants permission to the United States Government, including but not limited to the Federal Emergency Management Agency (FEMA), the State of Colorado, Larimer County, The City of Greeley, The City of Fort Collins, The Coalition for the Poudre River Watershed, The Big Thompson Watershed Coalition and each of their agencies, contractors and subcontractors, agents, and all others deemed necessary by these groups (collectively the “Permitted Entities”) to enter Owner’s property (“Property”) identified below and perform the following activities:  

1) Private Property Debris Removal (PPDR):  Owner gives permission to the Permitted Entities to enter the Property, including private roadways, to identify threats and hazards to public safety and to remove those hazards and structures, if any (Regular storm related debris does not fall under this project), including debris removal, erosion control efforts, and other post-fire related impacts; and/or    

2) Stream Bed Material Removal: Owner gives permission to the Permitted Entities to enter the Property to identify hazards and remove materials from waterway(s) that exist on the Property, if any; and agrees that any such debris may be temporarily relocated and held on the waterway bank, the right-of-way, or elsewhere on the Property until material is picked up and hauled away by the County; and/or

3) Clear and Grub: Owner gives permission to the Permitted Entities to enter the Property to identify hazards and remove materials, if any, that were pushed onto the Property from the road and right-of-way for the purpose of creating a temporary road (Regular storm related debris does not fall under this project); and/or

4) Seeding, Mulching, and Planting: Owner gives permission to the Permitted Entities to enter the Property to identify areas where seeding, mulching (both; aerial and hand mulching), and planting would have an erosion control benefit and distribute seed, mulch, and plants on the Property; and/or    

5) Installation of Erosion Control Measures: Owner gives permission to the Permitted Entities to enter the Property to identify areas where erosion control measures would prevent erosion and install these erosion control measures where the Permitted Entities see fit. These measures include, but not limited to, the armoring of private roadways, stream channel stabilization, wattle instillation, tree felling along contour, and silt fence instillation; and/or

6) Installation of Structure Protection: Owner gives permission to the Permitted Entities to enter the Property to identify areas where structure protection will protect life and property and install these structure protection barriers where the Permitted Entities see fit; and/or

7) Access: Owner gives permission to the Permitted Entities to enter the Property if necessary to gain access to any adjacent property for any of the above referenced activities.

Scope:  Owner understands that this Right of Entry authorizes the Permitted Entities to perform any or all of the above activities on the Property.  Owner further understands that the Permitted Entities are not obligated to take any action on the Property, and the extent or completeness of any work performed is in the sole discretion of the Permitted Entities.

Hold Harmless & Waiver:  Owner understands that the Permitted Entities cannot and do not guarantee that  efforts under this Right of Entry, if any, will prevent or limit damage to property or life. Owner agrees to indemnify and hold harmless the Permitted Entities for damages of any type whatsoever to the Property and/or to persons or property situated thereon.  Owner releases, discharges and waives all claims, losses, demands, actions or rights of action, either legal or equitable, that might arise by reason of any action or inaction of the Permitted Entities, whether known or unknown; and such entities do not waive any provisions of the Colorado Governmental Immunity Act, C.R.S. §§ 24-10-101 et seq., as amended, or other immunities or protections.

General characterization of work to be performed:  Large, heavy equipment, such as excavators and trucks, may access the Private Roads and Property if necessary to clear debris, load the debris into trucks and remove the debris from the Property.  Site restoration will be limited to damage caused by debris-removal activities.

Term:  The term of this right of access shall continue until December 31, 2022, unless earlier revoked by Owner in writing with such revocation being effective upon delivery to the Permitted Entities.

Duplication of Benefits:  Most homeowner’s insurance policies have coverage to pay for removal of wildfire or storm-generated debris and demolition of buildings damaged by storms.  Owner understands that Federal law (42.U.S.C. 5155 et.seq.) requires Owner to reimburse the Permitted Entities for the cost of removing storm-generated debris and/or demolition work to the extent that removal is covered by a homeowner’s insurance policy.  Owner also understands that he/she must provide a copy of the proof/statement of loss from Owner’s insurance company, if any, to Larimer County at 200 W. Oak St. PO Box 1190, Fort Collins, CO 80521.  If Owner receives in the future or has already received any payment from insurance or any other source for debris removal or demolition costs, Owner agrees to notify Larimer County of such payment in writing and provide all such funds and proof/statement of loss to Larimer County at the above address.  I understand that all disaster-related funding, including debris removal from private property and demolition costs, is subject to audit.

By signing this Right of Entry, Owner certifies that he/she is the owner, agent of the owner, or lessee of the Property, with authority to grant the rights herein.  Owner grants this right of access and entry to the Permitted Entities freely and without coercion and understands and agrees that this Right of Entry runs with the Property and is binding upon Owner’s heirs, executors, administrators, successors, and assigns.

Sign in to Google to save your progress. Learn more
Owners First Name *
Owners Last Name *
Address of Property (If there is no address for the property, please provide the road the property is located and the properties coordinates if you know them) *
Property Parcel ID # (if known)
Name the Property Record is listed under (i.e. Crystal Mountain Trust) *
Owner's Phone Number *
Owners Email Address *
Are there any barriers to access your property, either on your property, or the road leading to your property? (i.e. a locked gate) *
If yes, please describe
If you are part of a Road Association, Homeowners Association, or any other neighborhood group , please list it
Do you have homeowners insurance for this property? *
If "YES" please enter your policy number
Is this property your primary or secondary residence? *
Was a structure on your property damaged or destroyed during the fire? *
Please mark any of the following work you do NOT want to see done on your property.
Do you have any post-fire concerns on your property? Or anything else you'd like us to know?
By my electronic signature below, I affirm. *
[ ] I have read this Right of Entry and Work Authorization and understand that it involves important legal rights and obligations.                                                                                                                                                            [ ] I am the person identified as the Owner in this Right of Entry and Work Authorization.                                                                                                                                                  [ ] I am the legal owner of the Property, or an authorized agent of the owner or lessee of the Property, with full authority to grant the rights in this Right of Entry and Work Authorization.                                                                                                                    [ ] I desire the wildfire-related recovery and flood mitigation activities on my Property as described in this Right of Entry and Work Authorization.                                                                                                                                                                                          [ ] I grant the Permitted Entities the right to enter and perform work on my Property described herein, agree to all terms and conditions of this Right of Entry and Work Authorization, and affirm all of the information I have provided is true and accurate.      [ ] I approve the use of my electronic signature and agree its use shall be governed by Colorado’s  Uniform Electronic Transactions Act, C.R.S. §24-71.3-101 et seq.                                                                                                                                                     (your electronic signature is accomplished by typing your full name on the line below).
NO DUPLICATION OF BENEFITS CERTIFICATION *
Many homeowner insurance policies have coverage to pay for removal of fire-related debris and/or demolition of buildings damaged or destroyed by wildfire (“fire-debris work”). In addition, there may be other financial assistance programs to help pay for such fire-debris work on private property. Pursuant to a separate written agreement, Larimer County in coordination with other entities, agents, and contractors (collectively “Larimer County”) intend to perform fire-debris work on the property identified below (“Property”). In order to provide these services, Larimer County must verify that there will not be a duplication of benefits, meaning that you as owner of the Property do not have insurance coverage and have not received other financial assistance for the fire-debris work to be performed by Larimer County on your Property. Federal law prohibits duplication of benefits in §42 U.S.C 5155, et. seq.                                                                                                                                                             By electronically signing this No Duplication of Benefits Certification below, you, as the owner, authorized owner representative, or authorized lessee of the Property, certify that the following statements are true:                                                                                                                   • I am the owner, owner representative, or lessee of the Property with full authority to certify the truth of the statements in this form.                                                                                                                                                                                                                     • I have not received insurance proceeds or other financial assistance for the fire-debris work that I have authorized Larimer County to perform on my Property.                                                                                                                                                                                   • No insurance coverage is available for the fire-debris work that I have authorized Larimer County to perform on my Property.      • If I receive any insurance proceeds or other financial assistance for the fire-debris work that Larimer County performs on my Property, I acknowledge that I am required to reimburse Larimer County for costs it incurs in performing such work on my Property.
Date of my electronic signatures *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of co.larimer.co.us. Report Abuse
Google Forms