HomeMy WebLinkAbout6713 Flagler Rd - Special Inspections/Combustion Safety - 03/19/2013Cit'j/b#�
=fort Collins
Community Development and
Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
kgov. corn/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: %7 3 FW—L F_ IC F— I> Permit Number: 13 i 3G 117 Z
Contractor/Agency: tC, I-1 p— Equipment Replaced: W hT AIL Ik�RTr�-
Natural Conditions: Pass Fail Date Tested
(Failed test requires corrections until Natural Conditions test passe..)
Worst Case Conditions: Pass � Fail Date Tested 3 L9 /) 3
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)
00 r �-4 oj"
Owner's Signature Date 3