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<br />DNR HIRE -AT -FIRE EMERGENCY AGREEMENT - INCIDENT ONLY
<br />(1) DATE:
<br />(2) PROCUREMENT AGENCY: WA STATE DNR
<br />(3) AGREEMENT NUMBER:
<br />(4) INCIDENT/PROJECT NUMBER:
<br />Region: (check appropriate location)
<br />(i.e. WA-WAS-000004-0-2)
<br />(i.e. WA-WAS-000004)
<br />❑ Northeast ❑ Olympic ❑ Pacific Cascade
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<br />[Southeast ❑ Northwest ❑ South Puget Sound
<br />(5) INCIDENT NAME:
<br />(6) REQUEST NUMBER:
<br />Address (Street/City/State/Zip):
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<br />(i.e. 0-2)
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<br />`7 (3 'Rowers RZ
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<br />(7) POINT OF HIRE:
<br />(8) ORDERING DISPATCH CENTER:
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<br />(9) AGREEMENT EFFECTIVE DATES:
<br />Phone Numbers:
<br />[ ] Office: $C9' -ZS ' 9S %0
<br />Beginning Date O J 2—H
<br />❑ FAX:
<br />Ending Date: This is an incident only Agreement; expiring; at demobilization
<br />from the incident listed above. Reassigned resources need a new agreement.
<br />(10) CONTRACTOR NAME: �� c' CoL n.lir�y
<br />(11) WA STATE VENDOR PAYEE: (check appropriate box -fiscal staff)
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<br />❑ Contractor exists ❑ Contractor has completed paperwork
<br />(12)OPERATING SUPPLIES BEING FURNISHED BY: (check appropriate box)
<br />Address(Street/City/State/Zip):
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<br />[]CONTRACTOR (WET) ❑ DNR
<br />(13)THE OPERATOR WILL BE FURNISHED BY THE CONTRACTOR.
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<br />Phone ers:
<br />® Day: SI��itrr�-7525 ❑ Cell:
<br />❑ Night: ❑ FAX:
<br />(14) ITEM DESCRIPTION: equipment Include
<br />(15) No. of
<br />(16) OPERATOR name(s) and
<br />(17) RATE $: List
<br />(18) TYPE: List
<br />VIN, make, model, year, serial no., accessories
<br />OPERATORS
<br />phone number(s)
<br />applicable rate from the
<br />how rate will be
<br />or other identifying features.
<br />PER SHIFT:
<br />current DNR wage &
<br />applied; hourly,
<br />Equipment Rate Guide,
<br />daily, shift,
<br />orjustify other rate in
<br />mileage, etc.
<br />the Special Provisions
<br />Section below.
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<br />(19) SPECIAL PROVISIONS:
<br />(20) By checking each box and initialing, Contractor (or designee) certifies that he/she has read, understands, agrees, and accepts the terms/conditions as outlined.
<br />❑
<br />(contractor initials)
<br />I certify that I am 18 years of age or older.
<br />❑
<br />(contractor initials)
<br />I certify that I possess a current valid driver's license for the type of vehicle/equipment being operated.
<br />❑
<br />(contractor initials)
<br />I certify that I own, or have permission from the owner to operate, the vehicle/equipment contracted under this Agreement.
<br />❑
<br />(contractor initials)
<br />I certify that the vehicle/equipment contracted under this Agreement is in good working condition. 8
<br />❑
<br />(contractor initials)
<br />I certify that the vehicle/equipment contracted under this Agreement is properly licensed.
<br />❑ (contractor initials)
<br />I certify that I have the necessary wildland fire safety training and/or qualifications needed to operate a vehicle/equipment to
<br />perform or support fire suppression activities. This is evidenced through possession of a valid Incident Qualification Card or a
<br />wildland fire safety training document as outlined in RCW 76.04.181.
<br />❑ (contractor initials)
<br />I certify that I have read, understand, accept, and agree to the terms and conditions within the insurance section as outlined on
<br />page 2 (back side) of this Agreement.
<br />❑ (contractor initials)
<br />INDEMNIFICATION: To the fullest extent permitted by law, CONTRACTOR shall indemnify, defend, and hold harmless State,
<br />agencies of State and all officials, agents and employees of State, from and against all claims for injuries or death arising out of or
<br />resulting from the negligence of Contractor or the negligence of Contractor's agents and employees. "Claim," as used in this
<br />contract, means any financial loss, claim, suit, action, damage, or expense, including but not limited to attorney's fees, attributable
<br />for bodily injury, sickness, disease, or death, or injury to or destruction of tangible property including loss of use resulting
<br />therefrom. Contractor's obligation to indemnify, defend, and hold harmless State shall not extend to claims that arise from the sole
<br />negligence of State. CONTRACTOR waives its immunity under Title 51 RCW to the extent it is required to indemnify, defend and
<br />hold harmless State and its agencies, officials, agents or employees.
<br />❑ (contractor initials)
<br />I certify that I own or have permission from the owner to sign this Agreement on the owner's behalf.
<br />❑ (contractor initials)
<br />I have read, understand, accepted, and signed the conditions of the WAIVER AND RELEASE OF LIABILITY listed on page two (back
<br />side) of this Agreement. (Contractor name and signature REQUIRED on the back side of all four copies.)
<br />I certify, by signature below, that I have read this Agreement in its entirety, understand, agree, and accept all of the terms and conditions outlined within, that all of
<br />the information that I've provided is true and correct, and that I am authorized to act in the respective areas for matters related to this Agreement.
<br />(21) CONTRACTOR OR AUTHORIZED AGENT SIGNATj URE:
<br />(22 DNR AUTHORIZED REPRESENTATIVE SIGNATURE:
<br />Date: 1
<br />(23) CON R OR PRINTED NAME AND TITLE:
<br />(24 DNR MINTED NAME AND TITLE:
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<br />WA State Department of Natu al Resources (DNR) - SUBJ CT T CHANGE WITHOUT NOTICE 06/2016
<br />COPY DISTRIBUTION: (PINK = DNR Finance) (GOLD = Contractor) 7
<br />HITE = Ordering Office File) (BLUE = Equipment Time Recorder) Page 1 of 2
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