Medina County Building Department
791 W. Smith Rd.
Medina, Ohio 44256
Ph: (330) 722-9221
Fax: (330) 764-8204
Property Owner______________________________________________ Phone________________________________
Property Owner Address (if different than above) _________________________________________________________
articipant Hold Harmless, Waiver & Release
The undersigned applicant/owner hereby requests the Building Department staff of Medina County to conduct a
Water Voltage Safety Test at the Project Address listed above. In making this request, applicant/owner hereby grants
permission to the County’s Building Department staff to enter onto the subject real property for the purpose of testing
the body of water for electric voltage. Upon completion of the test, the County’s staff will provide the applicant/owner a
written result. If repair is required, the applicant/owner understands that the County will not repair nor contract for the
repair of any deficiencies found to be present and that any repair work found to be necessary is the responsibility of the
applicant/owner. Additionally, the applicant/owner agrees to use a licensed electrician to perform any necessary
repairs. Applicant/owner realizes that if an electric hazard is discovered, it is an immediate serious safety hazard and
the County’s staff will order the power to the equipment being investigated be turned off at its source until all necessary
repairs have been made. In certain cases an electric permit application and fee may be required for the repair.
In consideration for the testing of the water, the applicant/owner holds the Medina County Building Department and its
employees harmless and waive, release and discharge any and all claims for death, personal injury or property damage
which may occur. It is further understood and agreed that this waiver and release is binding upon any guests, invitees,
family members and heirs. Additionally, no guarantee is implied with the test, the test can only verify if a hazard is
present at the time of testing.
By signing below, you agree to all the terms of this hold harmless, waiver and release.
Applicant/Owner Signature_____________________________________________ Date ______________________
Print Applicant Name_______________________________________________ Phone _______________________
Email Address_____________________________________________________ Fax _________________________
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