HomeMy WebLinkAbout1705 Lake Sherwood Dr - Special Inspections/Combustion Safety - 09/04/2012Forof
t` Collins
TecA tr i k f i e+
Pryor PtR
Combustion Safety 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
970.416.2740
970.224.6134-fax
fcgov. com/de velopment
Address: i 705 Lq.Ice— 5kp_Y'"(Y i _ Permit Number: 01 a40JA/Or
Contractor/Agency: Prnr Pl knr 6 i y Equipment Replaced: 'A/ l y
Natural Conditions: Pass Fail Date Tested - 41-1 Z
O ut✓ (Failed test requires corrections until Natural Conditions test passes)
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Worst Case Conditions: Pass V' Fail Date Tested 4 - i `/ z P P n
Failed appliance information: /0/1
(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