Hold Harmless Agreement - Utilities (00540907xC4B6A)
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Return to and prepared by:
City of Boynton Beach
Utilities Department
124 E. Woolbright Rd.
Boynton Beach, FL 33435
PCN: _________________
Date: _________________
THE CITY OF BOYNTON BEACH
HOLD HARMLESS AGREEMENT
100 E. Ocean Ave.
Boynton Beach, Florida 33435
I/WE, __________________________________ am/are the property owner(s) of the real property
located at, ______________________ __________, FL, ______, Palm Beach County, Florida and
having the following legal description:
____________________________________________________________________________________
____________________________________________________________________________________
As the Property Owner(s), ____________________________________ agree(s) to protect, defend,
indemnify and hold the City of Boynton Beach, its officials, employees and agents, or successors
thereof, harmless from and against any and all lawsuits, penalties, damages, settlements, judgments,
decrees, legal costs, charges, removal, excavation, and replacement costs, any damages associated with
removal and/or excavation, and other expenses or liabilities of every kind in connection with or arising
from installation, maintenance, repair, removal, or excavation of utility equipment, lines or structures of
any kind whatsoever. Property owner(s) agree(s) and acknowledge(s) that should the City of Boynton
Beach, or its successor have to remove (description)__________________________________________
in order to conduct necessary maintenance, repair, or installation of utilities on said property, the
restoration costs associated therewith shall be the sole responsibility of Property Owner(s).
This Hold Harmless Agreement shall be recorded in the Public Records of Palm Beach County, Florida,
and shall encumber the above-described property, the property owner(s) and his or her successors and
assigns.
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PCN: _________________
WITNESS my hand and official seal on this _____ day of ___________________, 20__.
TWO WITNESSES as to Owner(s): INDIVIDUAL(S) AS OWNER(S):
____
First Witness Signature Owner Signature
____
Printed Witness Name Printed Owner Name
__________________________________
Second Witness Signature Owner Signature
____________________________ ____________________________________
Printed Witness Name Printed Owner Name
STATE OF ______________________ )
) ss:
COUNTY OF ____________________ )
I HEREBY CERTIFY that on this day, before me, an officer duly authorized in the State of Florida
and in the County of Palm Beach to take acknowledgments, by means of ___ physical presence or ___
online notarization, ____________________ acknowledged executing the same in the presence of two
subscribing witnesses freely and voluntarily and that the individual was personally known to me or
provided the following proof of identification: _________________.
(Notary Seal) _____________________________________
Notary Public Signature
_____________________________________
Printed Name of Notary Public
My Commission Expires: Commission Number:
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PCN: _________________
WITNESS my hand and official seal on this _____ day of ___________________, 20__.
WITNESS: CORPORATE ENTITY AS OWNER(S):
__________________________________
Corporate Name
____________________________ By: _______________________________
Witness Signature Name: _____________________________
____________________________ Title: _____________________________
Printed Witness Name Address: ____________________________
____________________________
Witness Signature
____________________________ {SEAL}
Printed Witness Name
ATTEST:
__________________________
Secretary
__________________________
Print Name
STATE OF _______________ )
) ss:
COUNTY OF ______________ )
I HEREBY CERTIFY that on this day, before me, an officer duly authorized in the State
aforesaid and in the County aforesaid to take acknowledgments, by means of ___ physical presence or
___ online notarization, _________________________________acknowledged executing the same, on
behalf of ___________________________________________ (Entity Name, and Type of Entity), as
named in the foregoing agreement, and that he/she acknowledged executing the same in the presence of
two subscribing witnesses freely and voluntarily under authority duly vested in him/her by said
________________ and that the ________________seal affixed thereto is the true corporate seal of said
________________.
(Notary Seal) _____________________________________
Notary Public Signature
_____________________________________
Printed Name of Notary Public
My Commission Expires: ________ Commission Number: _________