Application for 2015 El Dorado Fire Safe Council Senior Assistance Program Sponsored and Funded by El Dorado Fire Safe Council and Friends of Seniors Name(s) of property owner(s) _____________________________________________________ Street Address: _________________________________________________________________ Mailing Address (if different): _____________________________________________________ Assessor’s Parcel Number: (found on the tax bill) _____________________________________ Email: _______________________________________Phone: ___________________________ The State requires clearance of 100 feet from a structure or to the property line (Public Resources Code 4291). It is the homeowner’s responsibility to comply with California State Law. In some cases, based on the fuel type, topography, and weather conditions, 100 feet of clearance may not be sufficient to protect your home. The clearance provided by EDCFSC will focus on the 100 feet immediately surrounding your home. MORE, or a contractor, will perform the work designated on the evaluation form, up to a maximum of $300. The purpose of the work is to help create defensible space around your home, and to provide safe access along your driveway. The crew will rake, weed-‐ eat, remove brush and limb trees from around your structure. Trees that are recommended for removal are the homeowner’s responsibility. The crews will not clean roofs or gutters. Page 1 of 2 Hold Harmless: I/We understand that EDCFSC and Friends of Seniors are helping me/us clear around my/our home to assistance with compliance with Public Resources Codes. I/We, the landowner(s), shall not hold the EDCFSC, Friends of Seniors, MORE, or the contractor responsible for any damage to property or injury to persons that may arise out of the work performed or that may result from a wildland or other fire. I/We shall defend and hold EDCFSC, Friends of Seniors, MORE or the designated contractor, their officers, boards and commissions, and members thereof, and their employees harmless against and from any and all claims, suits, losses, damages and liability for damages of every name, kind and description, including attorney’s fees and costs incurred, brought for, or on account of, damage to property, or any economic or consequential losses which are claimed to, or in any way arise out of, or are connected with EDCFSC’s service, operations, or performance hereunder, regardless of the existence or degree of fault or negligence on the part of the EDCFSC, or employees of any of these, except as expressly prohibited by statute. I/We authorize members of the EDCFSC, their contractors and agents right of entry onto the property identified in this document. By signing this agreement you affirm that you are: age 65 or over, are both financially and physically unable to do the work yourself, and that your property is owner occupied. All owner(s) listed on the deed must sign below: _______________________________ Date: _______________________ _______________________________ Date: _______________________ _______________________________ Date: ______________________ Please mail completed and signed application to: Friends of Seniors P.O. Box 564 Placerville, CA 95667 Page 2 of 2