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Fort Collins Residential Energy Code
MECHANICAL DISCLOSURE FORM
mchdisc2.x1s—7/10/98
Neighborhood & Building Services
281 N. College Ave., P.O. Box 580, Fort Collins, CO 80522
Phone: 970 221 6760 FAX: 970 224 6134
Job Address:
General contractor: f7 e,.- D e ,/_.r /o D vyl -e i
Mechanical contractor: l�i! P SS I%
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 form must be made available to the original home buyer.
A. Space: heating system
Location
Fuel
Type
Manufacturer
Model #
Input capacity
kBtuh or kW
AFUE or
HSPF
B. Space cooling system
Location
Fuel
Type
Manufacturer
Model #
Input capacity
kBtuh or kW
I SEER
WIVZ1
�0
110
C. Waterheating system
Location
Fuel
Type
I Manufacturer
I Model #
Input capacity
I kBtuh or kW
Energy
I Factor
Storage
I volume
Certification
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 Job: (' < 5r 0115- ( ((
Signature: Gl/� Date:
Business Firm: All C 10�/>ivi--It
Address:
POS 02 G Phone: G�GI OS"UX