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Home My WebLink AboutCONSENT FOR ENTRY ACCESS FORM - 758 BROAD STREET AUGUSTA UTILITIES G E'r O R C i' # Tom D.Wiedmeier,PE Director AUGUSTA, GEORGIA UTILITIES DEPARTMENT Consent for Entry and Access to Private Property/ Liability Waiver and Release Address of property for which consent for entry and access being granted: 758 Broad Street Relationship to property: L (i.e., owner, owner's representative, tenant, etc.) The undersigned is (are) the owner(s), their representative(s), or otherwise control the real property at the location described above. It is necessary for Augusta Georgia to have entry and access to my property in order to have the Augusta Utilities Department's Contractor treat basement for any property damages resulting from a water main break. The undersigned fully understands that Augusta, Georgia and the Augusta Utilities Department deny any liability for any damages that may have occurred from the water main break, and that agreement and payment to the Contractor to perform treatment services to the Property Owner's basement is not an admission, nor will be used as evidence to imply admission of liability. The undersigned fully understands that the Augusta Utilities Department is having the Contractor perform treatment services in an effort to provide customer service to the property owner and to prevent any harm or damage to his/her property. The undersigned fully understands that the Augusta Utilities Department is having the Contractor to remove all or a portion of Property Owner's property in order to gain access to the basement for treatment, unless the property unreasonably blocks or obstructs access to the property and would be dangerous to remove. In consideration of the benefits derived from this arrangement, I(we)agree to the following: I (we) consent to employees and authorized representatives of the Augusta Utilities Department including their authorized employees, assistants, agents and subcontractors, entering and having continued access to my property for the following purposes: Augusta Utilities 452 Walker Street—Suite 200—Augusta,GA 30901 (706)312-4160—Fax(706)312-4123 www.augustaga.gov AUGUSTA UTILITIES --A.7 ,..........44. ,. I Tom D.Wiedmeier,PE Director 1. Remove all or a portion of Property Owner's property in order to gain access to the basement for treatment, unless the property unreasonably blocks or obstructs access to the property and would be dangerous to remove; 2. Allow the Augusta Utilities Department's Contractor to treat basement for any property damages resulting from a water main break; 3. Replace all or a portion of Property Owner's property in the same or similar location as situated prior treatment of the basement; and 4. (Other) I (we) WAIVE, RELEASE, AND DISCHARGE from any and all liability, including, but not limited to liability arising from the negligence or fault of the entities or persons releases, for personal injury, property damage, property theft, or actions of any kind which may hereafter occur during the treatment of the Property Owner's basement, THE FOLLOWING ENTITITES OR PERSONS: Augusta, Georgia, its Mayor, its Commissioners and their directors, officers, employees, representatives, and agents, (collectively referred to as the RELEASEES). I (we) ASSUME ALL OF THE RISKS OF the removal and relocation of contents of the Property Owner's basement, including by way of example and not limitation, and any risks that may arise from negligence or carelessness on the part of RELEASEES, from dangerous or defective equipment or property owned, maintained, or controlled by them or because of their possible liability without fault. I (we) understand, agree, and that acknowledge that Augusta, Georgia, its Mayor, its Commissioners and their directors, officers, employees, representatives, and agents are NOT responsible for the errors, omissions, acts, or failure to act to any party or entity as it relates to injury or property damage in regards to the above listed services in accordance with the treatment of the Property Owner's basement and/or the removal and relocation of contents of the Property Owner's basement. I (we) agree to HOLD HARMLESS AND PROMISE NOT TO BRING LEGAL ACTION against the entities or persons (RELEASEES)mentioned in the previous paragraph from any and all liabilities or claims made as a result or participation in the treatment of the Property Owner's basement and/or the removal and relocation of contents of the Property Owner's basement„ whether caused by the negligence of the entities or persons mentioned in the previous paragraph or otherwise. Augusta Utilities 452 Walker Street—Suite 200—Augusta,GA 30901 (706)312-4160—Fax(706)312-4123 www.augustaga.gov AUGUSTA UTILITIES G 0 R GI Tom D.Wiedmeier,PE Director This consent for entry and access, and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND AND IT'S CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL. In witness thereof, this agreement has been executed on the date and place so written. PROPERTY OWNER AUGUSTA,GEORGIA 00 _S.(-1i;,/ 04-1t ) I-1(374i-e Prin d Name I Printed Name Signature Signature ��4 1n 9'3 / . ire%• �, .',�,�r.� Date pate /�` ' _ �,� �• 409.,40 0 00 4 of w ° —"Ks se�®a - $ •+ r* ? $ ; 00 lowki.tolsob. Augusta Utilities 452 Walker Street—Suite 200—Augusta,GA 30901 (706)3124160—Fax(706)3124123 www.augustaga.gov Eih. . 1