Complete this form and mail it with the entry permit below to:
SOUTH LAKE FIRE SAFE COUNCIL
Bruce Anderson – P.O. Box 2 – Cobb, CA 95426 or to
James Ott – P. O. Box 942, Middletown CA 95461

The material must be stacked adjacent to roads and accessible to our contractor’s equipment without having to be moved.

The material must be free of rocks, dirt, berry vines, poison oak, tree stumps or construction material of any type.

Brush, tree limbs, and trees smaller than six inches (6”) must be stacked neatly and evenly with the butt ends all facing the road. Piles cannot exceed five feet (5’) in height.

Bulldozed piles or machine-stacked piles cannot be processed.

Piles cross-stacked or stacked so dense and compacted that the material cannot be pulled free to run through the chipper will not be processed.

Material must be cut to manageable twelve foot (12’) lengths maximum.

Request for Chipping:

Number of Piles ______ Size of Piles W________ (x) L ________ (x) H _________

Where is the material?    County Road {   }    Driveway {   }

Other:_______________________________________________________________

First _______________________ M.I. ___ Last_____________________________

Street Address _______________________________________________________

City/Subdivision: ______________________________________________________

Nearest Cross Street __________________________________________________

Assessor ’s Parcel # _____________________ Phone #______________________

Contact Address if Different _____________________________________________

Are you the property owner? Yes {   } No {   }

Owner ’s Name __________________________________Town________________

Do not submit this form until the material is stacked and ready for inspection.

I have completed the above referenced requirements. I understand that the South
Lake Fire Safe Council will make every attempt to perform the work on the
scheduled date, but due to unforeseen circumstances (such as weather,
equipment breakdowns, crew illness/injury or jobs taking longer than anticipated),
I also understand the work may be delayed.


Signature:

____________________________________________Date____________________

Pre-Inspector’s Notes:

For Office Use Only
Date Received _______ Date Entered _______ Date Inspected _______ Date Completed ________

Complete this form and mail it with the Chipping Request above to:
SOUTH LAKE FIRE SAFE COUNCIL
Bruce Anderson – P.O. Box 2 – Cobb, CA 95426

Permission for Right of Entry (Temporary)

Date:___________________________ Assessor's Parcel No.: ___________________

Permission is hereby granted to the South Lake Fire Safe Council, its officers, employees, designees and/or permittees to enter upon our land, identified as the above referenced parcel number, for the purpose of chipping brush and debris and all incidents thereto, pursuant to
the requirements of the Fire Safe Council's Chipping Program.

This is not a request for a permanent easement and/or right-of-way and this permission will automatically terminate upon completion of the work.

In consideration of permission granted, the Council agrees to, or has done, the following:

No structures of any type will be disturbed or damaged.
Any improvements on property, i.e. fences, driveways, landscaping, paving, etc.,
that are damaged or removed temporarily will be repaired and/or replaced.
Work will be performed in such a manner that it will not materially affect ingress
and egress to or from property.
No debris, wood chips or water material will be left on property, unless requested by
the land owner, and upon completion of work, property will be restores to pre-
construction condition as near as is practicable.

INDEMNIFICATION – HOLD HARMLESS AGREEMENT
COUNCIL to indemnify OWNER against loss or damage caused by an wrongful or negligent act or omission
of South Lake Fire Safe Council, its agents or employees in the course of their employment as may be
provided for in the California Entity Tort Claims Act.

COUNCIL further indemnifies and holds harmless OWNER from any and all claims, lawsuits, losses and
damages, brought for, or on account of, injuries to or death of any person or persons, arising out of, or
alleged to arise out of, or resulting from, the storage of materials and equipment by the South Lake Fire
Safe Council, its agents or employees on the property referenced herein, provided, however, that the
active negligence of COUNCIL, its agents or employees is excluded from this indemnity and hold harmless agreement.

By: __________________________________    _____________________________________
                        Owner's Signature                                                      PRINT Owner's Name

Address: ______________________________   _____________________________________
                                 Street                                                                         City/State

Telephone Number: _____________________ Email: _______________________________

RECOMMEND FOR APPROVAL: By ___________ Date: ______________________