MECKLENBURG COUNTY
FIRE MARSHAL’S OFFICE
Private Hydrant Release Form
Hydrant Testing Only
Authorizing Party or Person
Name of property or business
Address of property or business
Contact Party or Person Telephone number
The above Party or Person authorizes the Mecklenburg County Fire Marshal’s Office to
conduct inspection and test of the Owner’s private hydrant at the the above location.
Under no circumstances shall the Mecklenburg County Fire Marshal’s Office be liable in
any manner for the failure to conduct any inspection or test. The Authorizing Party or
Person above shall continue to be responsible for all maintenance of such hydrant,
including but not limited to, painting, repairing, and maintaining unobstructed visual and
physical access to all such hydrant. In addition, the Authorizing Party or Person is, and
shall continue to be, responsible for the costs of any and all water used to inspect
and/or test such hydrant.
The Authorizing Party or Person hereby releases, and shall indemnify and hold
harmless the County and if officers and employees from any liability, loss, and cost,
including, but not limited to, liability for property damage, loss of income, personal injury,
and reasonable attorney’s fees, arising or allegedly arising from the condition,
operation, testing, or inspection of the subject private hydrant and related
improvements.
The Party or Person shall maintain liability insurance covering the property described
above at limits of $1,000,000 per occurrence. A certificate of insurance evidencing this
coverage will be mailed to the Mecklenburg County Fire Marshal’s Office.
day of
This the
Party or Person Authorizing Participation:
Owner/Responsible Party or Person (circle one and print):
Address:
Tel. #
Signature and Title:
County Official Obtaining Authorization:
(Rank, Name, Station, Company)
PEOPLE • PRIDE • PROGRESS • PARTNERSHIPS
700 North Tryon Street • Charlotte, North Carolina 28202-2236 • (704) 336-2154 Fax (704) 336-3846
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