HomeMy WebLinkAbout110 N Shields St - Special Inspections/Combustion Safety - 02/21/201302/28/2013 16:08 9704938020 PAGE 02/02 '
Planning, Development & Transportation Services
City Of Community Deveiopment; Nei h
North College Avenue
P.O.O�°°d Services
P.Box 580
Fort Collins
Fart Collins, Co 80522,05$0
970.418.2740 _ n
970.224.8134 fax
kgavcom
Combustion Safety Test Compliance Form � � b
Replacement of Natural Draft Appliance
Address: ~o r 80009 5t0
� Permit Number:
Contractor/Agency:67 Equipment Replaced: /5;e��
Natural Conditions: pass pail
Date Tested a poi 3 (Failed test requires corrections until Natural Conditions test passes.) Worst Case Conditions: Pass X-_ Fail Date Tested
Failed appliance information:
(Failed test requires owner's signature acloiowledging 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)
Own r'.c %i n*+",.