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County of San Mateo Office of Emergency Services (County of San Mateo, California)

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County of San Mateo
Office of Emergency Services
Attn: Brian Molver
501 Winslow Street
Redwood City, CA 94063
Fax: (650) 363-1868
Email: czusmc@smcgov.org
Name of Owner(s)/Agent: ____________________________________________________
Phone Number of Owner(s)/Agent: ___________________________________________
Email of Owner(s)/Agent: _____________________________________________________
Property Address: _________________________________________________________
Assessor’s Parcel No. (APN): ________________________________________________
Right-of-Entry Permit for Debris and/or Hazard Tree Removal on Private Property
I / we, _______________________________________________________________________,
certify that I am / we are the owner(s), or authorized agent of the owner(s), of
the real property located at the above address (hereinafter “Owner”). I hereby
certify that I have full power and authority to execute this Right of Entry Permit
(ROE) without the need for any further action, including, but not limited to,
notice to or approval from any other party.
I / we hereby grant San Mateo County (“County”), as well as the State of
California (“State”), and the Federal Government, and their officers, employees,
agencies, and independent contractors (collectively, the “Government”), a
ROE upon the real property specified above by address and APN (hereafter the
“Property”) and will guarantee access to the property for the activities
described herein.
1. Time Period: This ROE shall expire 36 months after the date of the Owner’s
signature(s), below, or when the Debris and Hazard Tree Removal activities
described below are complete, as determined in the sole discretion of the
Government, whichever date is sooner.
Daniel T Belville
OES
Manager
Office of Emergency Services
501 Winslow Street
Redwood City, CA 94063
650
-363-4790 T
www.smcgov.org
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2. Purpose: The Government is granted this ROE to inspect, cut, test, remove,
and clear wildfire-generated debris of whatever nature including but not limited
to burned or partially burned structures, ash, concrete foundations,
contaminated soil, vehicles, trailers, waste, hazard trees or other debris from the
Property (“Debris and Hazard Tree Removal”).
3. Hazard Trees: Hazard Trees are wildfire-damaged trees that have been so
damaged by the fires that their structural integrity is compromised and that pose
an immediate threat of falling onto work crews or obstructing their access to the
debris clearance site, or falling onto a public right of way or public improved
property. The Government has sole discretion on whether to take or leave the
hazard trees, to determine whether a tree is hazardous, and to approve tree
removal from private roads. Debris and Hazard Tree Removal does not include
the removal of tree stumps.
4. Authorized Activities: Owner hereby grants to the Government, the right to
determine, in the Government’s sole discretion, which hazard trees, materials
and items on the Property are eligible and will be removed for Debris and
Hazard Tree Removal. Owner is responsible for removing, at Owner’s expense,
any items not eligible for Debris and Hazard Tree Removal. Owner’s failure to
remove items not eligible for Debris and Hazard Tree Removal may later be
deemed a public nuisance by local officials.
5. Reimbursement: All Debris and Hazard Tree Removal activities are provided
by the Government at no direct cost to Owner. However, the Owner agrees
hereby to file an insurance claim if Owner possesses homeowner’s, automobile,
or property insurance. Most homeowner’s insurance policies include coverage
for Debris and Hazard Tree Removal. State and federal law require Owner to
assign any Debris and Hazard Tree Removal insurance proceeds to the
Government to avoid a duplication of benefits (42 USC § 5155; 44 CFR § 204.62).
In consideration of the Government’s agreement to perform Debris and Hazard
Tree Removal, Owner agrees to inform the insurance company listed below of
this assignment and agrees to release their insurance information to the
Government. This ROE shall constitute Owner’s compliance with California
Insurance Code section 791.13 authorizing the insurance company to
communicate directly with the Government regarding any and all insurance
issues related to the Debris and Hazard Tree Removal.
Specified Debris and/or Hazard Tree Removal Insurance Coverage: If
Owner’s insurance in effect at the time of the wildfire provides specific
coverage for Debris and Hazard Tree Removal, then Owner hereby assigns any
and all rights, benefits, and proceeds with respect to these particular specific
coverages to the County and hereby authorizes that any benefits or proceeds
2
be paid directly and solely to County, in an amount not to exceed the actual
cost of the Debris and/or Hazard Tree Removal. Owner shall not be liable for any
further Debris and Hazard Tree Removal costs to County.
No Specified Debris and/or Hazard Tree Removal Insurance Coverage: If
Owner’s insurance in effect at the time of the wildfire does not provide specific
and separate coverage for Debris and/or Hazard Tree Removal, but such
coverage is included within another larger coverage category, then payment
to County shall be limited to the unused benefit amount, after the residence is
rebuilt. Owner hereby assigns any and all rights, benefits, and proceeds of any
unused benefit amount that is eligible for Debris and/or Hazard Tree Removal
remaining in a larger coverage category to County, in an amount not to
exceed the actual cost of the Debris and/or Hazard Tree Removal.
Specified Automobile Insurance Coverage: If Owner’s automobile
insurance in effect at the time of the wildfire provides specific coverage for
vehicle removal, then Owner hereby assigns any and all rights, benefits, and
proceeds with respect to these particular specific coverages to the County and
hereby authorizes that any benefits or proceeds to be paid directly to County, in
an amount not to exceed the actual cost of the vehicle removal. Owner shall
not be liable for any further vehicle removal costs to County.
No Specified Automobile Insurance Coverage: If Owner’s automobile
insurance in effect at the time of the wildfire does not provide specific and
separate coverage for vehicle removal, but vehicle removal coverage is
included within another larger coverage category, then payment to County
shall be limited to the unused benefit amount. Owner hereby assigns any and all
rights, benefits, and proceeds of any unused benefit amount that is eligible for
vehicle removal remaining in a larger coverage category to County, in an
amount not to exceed the actual cost of the vehicle removal.
In the event the insurance company or companies listed below issue
insurance proceeds for Debris and Hazard Tree Removal or vehicle removal
directly to Owner, then Owner shall promptly inform the County of the amount
of such proceeds and remit such insurance proceeds to County, not to exceed
the actual cost of the applicable Debris and/or Hazard Tree Removal.
3
Homeowner’s Insurance (please attach a copy of your policy):
Insurance Company:
_____________________________________________________
Policy Number:
_________________________________________________________
Claim Number:
_________________________________________________________
Agent’s Name:
_________________________________________________________
Agent’s Phone / e-mail:
__________________________________________________
Secondary Insurance, or personal property insurance for other damaged items
on the Property (please attach a copy of your policy):
Insurance Company:
_____________________________________________________
Policy Number:
_________________________________________________________
Claim Number:
_________________________________________________________
Agent’s Name:
__________________________________________________________
Agent’s Phone / Email:
____________________________________________________
4
Automobile Insurance for car, boat, trailer or other vehicles on the Property
(please attach a copy of your policy):
Insurance Company:
_____________________________________________________
Policy Number:
_________________________________________________________
Claim Number:
_________________________________________________________
Agent’s Name:
__________________________________________________________
Agent’s Phone / Email:
____________________________________________________
If Owner does not have homeowner’s and/or automobile insurance, or
other similar insurance, then Owner certifies under penalty of perjury by his/her
signature below that no insurance coverage for the costs associated with fire
Debris and/or Hazard Tree Removal at the Property was in effect at the time of
the wildfire:
_______________________________________ ________________________________
Owner’s signature Date
_______________________________________ ________________________________
Owner’s signature Date
_______________________________________ ________________________________
Owner’s signature Date
Any property that is sold prior to issuance of the cleanup certification will
be withdrawn from the program, unless both new and former Owners sign a
property transfer affidavit. Costs for work completed will be billed to the
insurance company listed above if applicable.
6. Waiver of Liability: Owner acknowledges that the Government’s decisions
about when, where, and how to provide Debris and Hazard Tree Removal
services on Owner’s property are discretionary functions. Owner hereby
acknowledges that the Government is not liable for any claim based on the
exercise or performance, or failure to exercise or perform, a discretionary
function, and promises not to make such a claim. Owner further releases and
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agrees to hold and save harmless the Government from all liability for any
damage or loss whatsoever that may occur during or after performance of the
Government’s Debris and Hazardous Tree Removal activities. Please also see
sections 10 and 11, below. Owner therefore waives any claims or legal action
against the Government. This indemnification is required by state and federal
law, including the California Emergency Services Act, California Government
Code section 8655, California Code of Regulations, Title 19, section 2925, and
the Stafford Act, 42 United States Code, sections 5148 and 5173. Nothing in this
section impacts the Owner’s right to pursue claims with insurance companies
under their applicable insurance policy or policies.
Owner agrees that the methodology for identifying and removing hazard trees,
and other debris material, and the selection of personnel to identify hazard trees
and other debris material, shall be at the sole discretion of the Government and
Owner expressly waives and releases any claims in that regard. Owner
expressly waives his or her rights to bring proceedings in law or equity against
the Government with respect to the identification and/or removal of hazard trees
and other debris material.
7. Foundations: In order to participate in this program, Owner must allow
removal of all foundations from the subject Property. Stem walls and retaining
walls may be left on a case-by-case basis, as approved by the State. Owner
acknowledges and understands that the removal of a foundation may leave a
depression in the ground, and that it is Owner’s responsibility to fill any
depression(s) following the removal of a foundation.
8. Soil Sampling: Debris removal includes taking soil samples in the debris
footprint to ensure that all contaminants have been removed. If initial soil
samples do not meet the cleanup goals for this project, then additional soil will
be removed from the debris footprint and more soil samples will be taken.
Owner acknowledges and hereby authorizes the Government to remove
enough soil to ensure cleanup goals have been met. Owner acknowledges this
may leave a depression on the Property and that it is Owner’s responsibility to fill
any depression left on the Property.
9. Markings of Infrastructure Facilities: Owner agrees to make their best efforts to
mark subgrade utility lines (sewer, water, electricity, gas, cable, etc.), and to
mark the location of septic tanks, leach fields, water wells, hand dug
wells/cisterns, or other subgrade structures. Owner should carefully complete the
attached Property Information Form and append any maps, diagrams, or
legible notes that may be useful to the Government’s contractor in locating
subgrade structures and instructing the crews which items the Owner may want
to remain on the Property following Debris and/or Hazard Tree Removal. The
Government will endeavor to avoid all marked structures, however, Owner
6
acknowledges pursuant to Section 6, they indemnify, hold and save harmless
the Government from any damages to marked or unmarked structures.
10. Driveway, Roadway and Other Incidental Damage: Multi-ton excavators
must perform much of the demolition, consolidation and loading of fire debris
into trucks for removal to appropriate recycling and disposal and end use sites.
The scale and weight of this equipment, and the weight of loaded trucks
hauling debris out of fire-damaged neighborhoods, often exceeds the design
capacity of residential driveways, sidewalks, and roadways. Crews will take
reasonable precautions to mitigate against damage. However, Owner
acknowledges cracking and damage to asphalt and concrete pavement is a
common and unavoidable consequence, and is therefore considered
incidental to Debris and Hazard Tree Removal. By signing this ROE and opting
into the Government Debris and Hazard Tree Removal at this Property, the
Owner acknowledges the risk of such incidental damage as well as responsibility
for the cost of any repairs to private property or jointly-owned private roadways
that may be caused by Government contractors in the performance of Debris
and Hazard Tree Removal operations. Owner hereby promises to indemnify,
hold and save harmless the Government from any repair claims described
above, or any other incidental and unavoidable damage occurring as a result
of routine operations associated with such Debris and Hazard Tree Removal.
11. Damage to Improved Property: Debris and ash removal crews will attempt to
minimize impacts to improved property that was not damaged by the fire.
Owner may submit a complaint regarding any improved property that Owner
believes was damaged during the Debris and Hazard Tree Removal operations
at czusmc@smcgov.org. However, Owner acknowledges Section 6 of this ROE
limits the liability of the Government with respect to such damage, if any.
12. Erosion Control: Owner acknowledges that erosion control measures may be
necessary, such as wattles and hydromulch, to stabilize soil on or about the
Property. Such erosion control measures are at the sole discretion of
Government.
13. Modification: The provisions of this ROE may not be modified. Owner may
cancel this ROE only by submitting an executed Withdrawal Form to the County
at czusmc@smcgov.org (see below).
14. Fraudulent or Willful Misstatement of Fact: An individual who fraudulently or
willfully misstates any fact in connection with this ROE 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 United States Code,
section 1001.
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15. Public Records Act: Owner acknowledges that completed ROE forms may
be subject to public disclosure under the California Public Records Act
(Government Code section 6250 et seq.). Other state and federal laws may
apply. While efforts will be made to redact personally identifiable information,
such redactions will be made at the sole discretion of Government.
_________________________________________________________________________
Printed name of Owner or Agent
_____________________________________________ __________________________
Signature of Owner or Agent Date
_________________________________________________________________________
Printed name of Owner or Agent
_____________________________________________ __________________________
Signature of Owner or Agent Date
________________________________________________________________________
Printed name of Owner or Agent
_____________________________________________ __________________________
Signature of Owner or Agent Date
______________________________ _____________________________________________
Phone number of Owner or Agent E-mail address of Owner or Agent
_____________________________________________________________________________
Mailing address of Owner or Agent
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Approved by County of San Mateo and verified that the Property, APN, and
Owner are accurate and meet the eligibility requirements of program:
_____________________________________________________________________________
Title and Printed name of County Representative
_____________________________________________ __________________________
Signature of County Representative Date
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Disaster Debris and Hazard Tree Removal Program Property Information
Please identify all that apply on the Property:
Vehicles
Location
Description
Comments
Car
Boat or Trailer
Other vehicles
(ATVs,
motorcycles,
trailers, vans,
motorhomes,
recreational
vehicles, trailers,
etc)
Other (farm
equipment,
construction
equip, etc):
Underground
Tanks
Construction
Date (If
Known)
Comments
Septic
1
Tanks
and Leach
Fields
Fuel/Oil
2
Water
Other:
1. Septic tanks will be pumped of all waste as part of the Debris and Hazard Tree
Removal project only if they posed a hazard to crews.
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2. Owner must provide documentation of ownership for large propane tanks to
be removed.
Underground
Structures
Location
Construction
Date (If
Known)
Comments
Basement
Root Cellar
Other (water
wells,
cisterns/dug
wells, mine shafts,
etc):
11
Insert or Draw Map of Property
12
STOP HERE AND DO NOT FILL OUT THE BELOW PAGE UNLESS YOU WISH TO
WITHDRAW FROM THE DEBRIS AND HAZARD TREE REMOVAL PROGRAM
Withdrawal Form
To cancel this ROE, this Withdrawal Form must be signed by the Owner and
either emailed to czusmc@smcgov.org or mail to:
Office of Emergency Services
Attn: Brian Molver
501 Winslow Street
Redwood City, CA 94063
of the County in which the Property is located at, and acknowledged by an
authorized employee in advance of Debris and Hazard Tree Removal activities
at the Property. Allow at least three (3) days to process.
Alternatively, the ROE may be cancelled at the Property site by obtaining the
signature of designated San Mateo County Representative present when the
crew appears for work. Due to scheduling constraints, the Government cannot
provide specific dates and times when they will be available at the Property site
to accept a cancellation. Owner should therefore turn in the Withdrawal Form
at the location designated by the County in the above paragraph if possible.
I have read and understand the foregoing statement concerning cancellation
policies. I hereby certify that the Debris and Hazard Tree Removal at the
Property has not yet commenced, and that I request to cancel the Right of Entry
(ROE).
_____________________________________________________________________________
Printed name of Owner or Agent
_____________________________________________ __________________________
Signature of Owner or Agent Date
______________________________ _____________________________________________
Phone number of Owner or Agent E-mail address of Owner or Agent
_____________________________________________________________________________
Mailing address of Owner or Agent
13
I hereby acknowledge receipt of the foregoing request for cancellation:
_____________________________________________________________________________
Title and Printed name of County Representative
_____________________________________________ __________________________
Signature of County Representative Date
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Completed 24 June 2021

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