HomeMy WebLinkAbout2912 Mercy Dr - Special Inspections/Combustion Safety - 05/07/2013Sity of
Fort Collins
Approved Agent Signature:
4RWb
-vt•me1y"CombuitionSafety Test Compliance Form
Replacement of Natural Draft Appliance
Community Development and
Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970A16.2740
970.224.6134-fax
fogov.com/devokpment
Address: IPermit Number:
Contractor/Agency: Riggallit, F t,w�T— Equipment Replaced: 5osgl N6 "&e ke
FBI Z—M��
Natural'Conditions: Pass Fail Date Tested
(Failed test requires corrections until Natural Conditions testpasses)
Worst Case Conditions: Pass / Fail Date Tested S /-1 �l3
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 �?� - �`�� �— V i Date S- 7 - I Z