HomeMy WebLinkAbout5308 Parkway Cir - Special Inspections/Combustion Safety - 07/19/2013Planning, Development& Transportation Services
City of Community Development & Neighborhood Services
O i 0 nS P.O.N College Avenue .
I (v P.Box
580
^ Fort Collins. CO 80522.0580
970.416.2740
970.224.613+ Fax -
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: wPermit Number: '6�3dl�jp
Contractor/Agency. �tlr�asfl Equipment Replaced: 7ei X4�17<' "
Natural Conditions: Pass Fail Date Tested"
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass X Fail Dafe,Testet3
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
Date