HomeMy WebLinkAbout1901 Bronson St - Special Inspections/Combustion Safety - 10/19/2013Planning, Development & Transportation Services
City Of Community Development & Neighborhood Services
Fort Collins281 rth College Avenue
P.O.P.
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form j� 13 Q g�
Replacement of Natural Draft Appliance
Address: l`Ja/ %3AAlf-olv SF
JW6-
Permit Number:
Contractor/Agency: Dee- kHElY9V C/2 uipmentReplaced:
Natural Conditions: Passe Fail I�IV Date Tested
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass \ Fail /y Date Tested
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 17 //51V