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<br />DNR HIRE-AT-FIRE EMERGENCY AGREEMENT - INCIDENT ONLY
<br />l1f DArE:Qlrol aq
<br />{14} ITEM DESCRIFIION: equipment lnclude
<br />VlN, make. mode|. year, serial no., accessories
<br />or oth€r identifying features.
<br />(19) SPECTAL PROVTSTONS:
<br />(r5) No. of
<br />OPERATORS
<br />PER SHIFT:
<br />each box artrl ilutr.l ling, Contra6tor (or derignee) certities ihat he/she ha: read, understands, agree5, and accgpts the terms/conditions a5 outlined.
<br />init that I am of or older
<br />inrt ihat I lg:S:: s glgglvalid drive/r_licen:e {or the iyp_e-gf "ve!_qLry&q-,19.mgl!.q91ts.9!91?.!ed-_.,_
<br />init that I own, or have lrom the owner to contracted under this ent.
<br />rac!ot inrtr.ll I car that the contracted under this I5 rn condition.
<br />I certify ihat the ve!clergryg mgc gl$geqlnq!I this menl rt
<br />d.,
<br />licensed
<br />I certify that ! have the necesrary wildland fire ralety training and/or qualificationt needed to opetate a vehicle/equipment to
<br />perform or support fire suppresston 3ctivities. lhis ts evrdenced through possession of a valid tncrdent Qualif ication Card or a
<br />r!$l4qjr!g-lnrgtv !I1l1lt3-,q9( 911q1! ls,oulll'19! in 8.9ryJ-93, 1q,!
<br />I cert'fy that I have read, undetstdnd. .rcceot, and agree lo the term5 and conditio']s withln lhe Insurance
<br />,.....:.____1991t1,.1c]o. rnltialsi
<br />_ (contraclor inirials)
<br />{.or)tracior ioitialr}
<br />{aorrtractor initia!si
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<br />sectron a5 outlined on
<br />I hold harmless State and tls agencies. officials, agents or emolovees.
<br />{con!rac:or inrtials}I certr that I own or have permiscion from thc own€r to siRn this Agreement on the owner's behalf
<br />__ {contrac:or inrtralsl I have read. undetstand, accepted, and siSned the conditions of the WAIVER AIYD RELIASE OF UABILITY iisred on page two (back
<br />! side) of thrs As,:gy'e!tJco!!!octy !g!:and on the back tide all
<br />I certify, by signature below, lhat I this Agreement io its entrrety, understand,rgree, and acacpt alt of the te]ms end conditions outlined withrn, that all of
<br />that
<br />have read
<br />is trua end and lo.ct in the related to this
<br />DNR AUTHORIZED REPRESENTATIVE SIGNATURE
<br />DNR INTED NAME AND TITLE{23}
<br />pige ? l9nct:!49i9! lhr! A_eleemenl.
<br />INDEMNIFICATION: To the tullesr eetent peroritted bV law, CONTRACTOR 5hall indemnifY, defend, and hold harmless State,
<br />dtenctes of St,rte dnd all of{ioal:, dtent5 dnd enrployees of 5tale, iron} and againlr all claims for inlurie5 or death arisrt}8 out of or
<br />resulting from the negligence ol Contractor or the negligence of COntractor's ngents and employees. "Clalm,'3s used In thrs
<br />coltr3ct, r1ed1s a1y financial lgs:. clarrn, :uil, Jction, d,]nlaBe, o. expense. tncludiag but rrut limlted to attorney's fees attrrbutlble
<br />for bodily tniury, sickoess. direase, or death, or injufy lo or desttuctron of tangrble properlv lncluding los: of use re5ultlng
<br />therefrom. Contracio/s ob!igation to rndemnify, defend, and hold harmles5 State thall not extend to claim5 that a.ise from the soie
<br />negligence of State CONTRACTOR waives iri immunity under Title 51 RCW to the extent !! is required to indemnily, defend arrd
<br />PRINTED NAME AND TITLE
<br />Fao ;kh:Y;06l2016
<br />PaBe I ol 2
<br />WA State Departmen sources {DNR}CHAI{GE W|THOUT
<br />(4) INCIDENT/PROJECTNUMBER
<br />(i.e wA'wAs-000004)
<br />{s} INCIDENT NAMEr
<br />$ns.f Cre.C.,K
<br />WA-SES
<br />E-\
<br />tu
<br />(3} AGREEMENT NUMBER:
<br />{i.e. WA-WA5-000004-O-2}
<br />(6} REQUEST NUMEER:
<br />{r.e. O-2}
<br />(E, ORDERING DISPATCH CENTER
<br />\dr+(^)-c(7) POrNT OF H|RE;
<br />E,
<br />Ending Datel rhis i5 an incident only Agreement; expirinn at demqbililation
<br />(e)AGR€EMENT EFFECT]VE DATES:q l,o lzLlBeginning Date
<br />frorn the incrdent !isted above.resources need a
<br />(11) WA STATE VENDOR PAYEE: lcheck appropriote box - fiscot stalf)
<br />Contractcr lrasConlfactor exiSts
<br />(f 2IOPERATING SUPPLIES BEING FURNISHED BY: (check opprosrldte box)
<br />DNRCONTRACTOR
<br />(13)THE OPSRATOR WllL 8E FURNISHED 8Y THE CONTRACTOR.
<br />{Z) PROCUREMENT AGENCY: WA STATE DNR
<br />Region : {check appropriate locatron}
<br />I olymprc f] Pacific cascacte
<br />I Northwest ff south Puget S{]un(t
<br />Address (StreeVCity/5tat€/zipl:
<br />-713 Bour.g's RGcf
<br />lir\ensrcur!r u:F g9fizJa
<br />Phone Numbers:
<br />fi orice Saq'qz 5 ' gs lO
<br />fl mx,
<br />(l0lCONTRACTOR NAME: Ki Hi\t.S Courrlrr
<br />She.r\{+'" g{S'ce
<br />Address {StreeVCity/5tate/zip}:
<br />FAI:
<br />I northeast
<br />ftoutt east
<br />{18} WPE: usr
<br />how late will be
<br />rpplad; bourly.
<br />daiv, shilt
<br />mileage, etc
<br />D \
<br />(171 EATE 5: rist
<br />rpplicable nte Irom the
<br />currcnt DNR Wage &
<br />Equ,pment nate6uade,
<br />orluslify oth€r nte m
<br />the 5geiil P.oviriN
<br />iu\h0n
<br />(161 OPERATOR nametsl and
<br />phone number{s}
<br />{21) CONTRACTOR OR AUTHORIZED AGENT SIGNATURE
<br />T3 oiltttzlDate:
<br />roffi
<br />COPY OlSTBlBt IION: IPINK . DNR Finance] (GOLD . Contractot]: Ordering Office File) {BtUt = Equipn'ent flme Recorder}
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