HomeMy WebLinkAbout2204 Purdue Rd - Special Inspections/Combustion Safety - 01/03/2014Sn N. 6-rcA,-t ` t6G sg3l
Planning, Development & Transportation Services
City Of Community Development & Neighborhood Services
Collins P.O.281 Bo h College Avenue
F P.O. Box 580
ort
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: ,22ol 17&,,due Permit Number: r,ti
Contractor/Agency: Equipment Replaced: G i.,�,1.vl��r
Natural Conditions: Pass Fail Date Tested
(Failed test requires corrections until Natural Conditions test passes)
Worst Case Conditions: Pass Fail Date Tested I 3 ILI4
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) Q�� �O J'�-
Owner's Signature
Date