CITY OF ROSSFORD, OHIO

SPECIAL USE PERMIT FOR FIRE HYDRANTS

The undersigned hereby has been granted a permit for special use of a fire hydrant located with the City, provided the use is limited to and in conformity with the special permission granted and stated below. This is according to City of Rossford Municipal Code 521.12, Ordinance 538.

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Date:__________________________

_________________________________________________________________ has been given

authorization to make use of fire hydrant number ____________________ located at

____________________________________________________________ for the sole purpose of

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Minimum fee for use of fire hydrant: $10.00

(Please Print)

Name:____________________________________________________________________________

Address:__________________________________________________________________________

Telephone No:______________________________________________________________________

Signature:_________________________________________________________________________

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Approved by: ______________________________________________
                          City Administrator