Lake County, FL Right of
Entry Statement
Info
Property Owner / Tenant Name:
Property Address / Description:
City:
Right of Entry
I certify that I am the owner, or an owner’s authorized representative of the above described
property. I grant, freely and without coercion, the right of access and entry to said above described
property to Lake County and its contractors for the purpose of collecting storm debris in the right of
way near or on my property. The term of this Right of Entry Statement shall be in effect upon date
of my signature below and will remain in effect for and during the current emergency event. In
consideration of the work to be done by the County, I agree to defend and hold harmless the County
from any losses, damages, and costs resulting from omission or negligent act of the County, its
agents or employees as part of this Right of Entry Statement.
Names and Signatures
Sworn and attested: Date:
Property owner or agent signature
Print name:
Printed name of property owner or agent
Witness Signature:
Print name:
Printed name of witness
Mail to
Road Operations
P.O. Box 7800,
Tavares, FL 32778
352-343-6439
click to sign
signature
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click to sign
signature
click to edit
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