HomeMy WebLinkAbout1637 Tanglewood Dr - Special Inspections/Combustion Safety - 02/21/2013Planning, Development & Transportation Services
.,_,-F Community Development & Neighborhood Services
� V ! ��� �� 281 North College Avenue
P.O. Sox 580
,r Fort Collins. CO 80522.0580
970.416.274e
970.224.6134- fax
cgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: i(,3 7 T s ��%^ Permit Number: Q( 3 Qo 4 5�
Contractor/Agency: � Z , kOA Equipment Replaced: X/
Natural Conditions: Pass Fail Date Tested
(Failed test requires correc ns until Natural Conditions test pusses.)
Worst Case Conditions: Pass � Fail Date Tested 2/2)//;—
Failed appliance information:
(Failed test rewires otivner'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