Temporary Gas Service Letter Template - City Of Fort Worth Planning & Development Department

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City of Fort Worth – Planning & Development Department – Plumbing Division
Application for Temporary Gas Service
Fax Number – 817-392-8116
Temporary Gas Service Letter
The owner and plumbing contractor agree to insure that all gas piping and heating appliances are complete.
The owner/applicant agrees that, if upon inspection of said premises by an plumbing inspector; he/she; the
applicant will make all necessary changes to said plumbing in conformance to the requirements of the current City
of Fort Worth Plumbing Code. The owner/applicant further agrees that, if any other city inspection violations are
so noted by other divisions of the City of Fort Worth; and have not been corrected, or if the changes have not been
made within sixty (60) days after such inspection, the City may have service disconnected to said owner/applicant
until such changes have been made and approval by the plumbing inspector has been given.
The owner/applicant agrees to release the City of Fort Worth, and its agents from any and all liability of every
kind and nature for damages to persons and/or property which may occur from defective gas piping methods
and/or gas supplied equipment and hereby agrees to indemnify the City of Fort Worth and its agents for and to
hold the City of Fort Worth and its agents harmless from any and all such liability.
___________________________________________________________________________________________
APPLICANT USE:
WARNING:
Signing of this document does not authorize
occupancy of this structure.
Applicant Initial ____________
rd
Comm: _____ Resd: ______ 3
Party: _____
___________________________________________________________________________________________
Related Build/Ordinance Permit Numbers (If Applicable):____________________________________________
Job Address: ________________________________________________________________________________
Owner/Agent (Print): ____________________________________________ Telephone: ___________________
Master Plumber (Signature): _________________________________________ FW Reg #: ________________
Master Plumber (Print): ____________________________________________ FW Reg #: _________________
Return Fax Number: __________________________________________________________________________
I hereby certify that I am the owner/authorized agent of said property and that the information given above is true
and correct to the best of my knowledge. I further agree to the condition of this letter.
__________________________________________
______________________________
Owner/Agent Signature
Date
Payment Methods Available:
Master Card: _____Visa: _____ American Express: _____ Discover: _____
C
ard #: _________________________________ Expire Date: ___________ 3 Digit CVS Code: ________
C
ardholder’s Name: ________________________Card Street Billing Address: ______________________
S
ignature: ___________________________________Card Billing Zip Code: ________________________
___________________________________________________________________________________________
OFFICE USE:
PERMIT #: ________________________________________ Hook-Up Dates: _________________________
Inspectors Signature: __________________________________ Date: _________________________________
Revised 060407.OEE

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