HomeMy WebLinkAbout5118 Abbey Rd - Special Inspections/Combustion Safety - 06/05/2013C
Planning, Development & Transportation Services
City of Community Development & Neighborhood Services
281 North College Avenue
Fort Collins., P.O. Box580
Fort Collins, CO 80522.0580 "
970.416.2740
970.224.6134- fax '
fcgov.com
.Combustion Safety Test Compliance Form
"Replacement of Natural Draft Appliance
Address: Permit Number:
Contractor/Agency: �� �i w 1�-� Equipment Replaced: ZZ--"7e /7111;��
Natural Conditions: Pass Fail Date Tested .
(Failed test requires corrections until Natural Conditions. -test passes:)
Worst Case Conditions: Pass Fail Date Tested - ✓ -- %3.
Failed appliance information: .
(Failed test requires owner's signature acknotivIedging results.)
0
I certify that I am the legal owner of the above listed property. and herebyacknowledgethat my
appliance has failed a Combustion Safety Test under worst -case conditions.'
Owner's Name (print)
Owner's Sianahira ,,