HomeMy WebLinkAbout3014 Indigo Ct - Special Inspections/Field Verification - 03/28/2012city
Community Development and
Neighborhood Services
Fort Collins C& 281 North
ox580College Avenue
P.O. Bea 580
Fort Collins, CO 80522.0560
970AI&2740
970224.6134- fax
fcgov coarn/deMopment
Approved Agent Signature:
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: 3 a 1 -f C , FT /Co 2z;lj Permit Number: 3 110 15 3 3
Contractor/Agency: Q�`�ua �ine �lu.dYlI.1NG Equipment Replaced: Pa loa l NG 100-4 y P.t�
Natural Conditions: Pass Fail Date Tested
(Failed test requires corrections until Natural Conditions test passes)
Worst Case Conditions: Pass Fail Date Tested 3 18
Failed appliance information:
(Failed test requires owner's signature acknowledging results.)
I certify that I am the legal owner of the above listed property and hereby acknowledge that my
appliance has failed a Combustion Safety Test under worst -case conditions.
Owner's Name (print)
Owner's Signature Date