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Fort Collins Residential Energy Code
MECHANICAL DISCLOSURE FORM
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POSEPTS HEATING& AIP PAGE 03/04
the budding & zoning dept of
Community Planning and Environmental Services
281 N Collette Ava P 0 Box SW Fort Collins, co 80522
Vokcc 97tl 221 M W FAX 970 224 6134
Job Address D 3 K-'i cW e Y2 w-i rj e, tr
General contractor `� cf-'s t D W Yt 6 L L i I d r Is
Mechanical contractor - -�h 6 e.r 15 LIL D, L 1 r( !Q A iT n_
��. i r _ �n C
INSTRUCTIONS
This disclosure form Is to be signed by the mechanical contractor or representative Of the general contractor
Please type or print except for the signature
If there are multiple systems serving any function make multiple entries to describe them
One copy of this form must be provided to the Building and Zoning Department prior to the C O
One copy of this farm must be made available to the original home buyer
A Space heating system
Location
Fuel
Ma ut eturer
Mpdet
Input capacity
Wtuh or kW
AFuE or
HSPF
CX.S2rne,
d5
u -o t
l-e-rinc
y3uF3,A oqt)
B Space cooling system
Location
Fuel
Tvpe.
Manufacturer
Model#
Input capacity
kBtuh or kW
SEER
C water heating system
Location
1 ue1TvDe
Ma ufa4'turer
Model X
Input Capacity
kBtuh or kW
Energy
Factor
storage
volume
Certfificatton
I/We certify that the above listed equipment (including ducts and piping) Was installed in the building at the above locations
in conformance with the requirements of the Fort Collins Residential Energy Code and Mechanical Code and further that
such equipment was installed in accordance with manufacturers instructions
Person Certifying
D t e-o ate,
Date In 12.6 1 ri S
Susiness Firm k o be r i s H e ct+i r-1 �1i r, T n,_ I'