HomeMy WebLinkAbout2725 Antelope Rd - Special Inspections/Combustion Safety - 05/07/20141UN/17/2014/TUE 02:39 PM Delta Mechanical Inc FAX No.866-692-5275 P,001/001
Fort Collins
.
Planning, Development & Transportation Services
Community Development 6 Neighborhood Services
281 North College Avenue
P.C. Box 580
Fort Collins, CO $0522,0580
970.416.2740
970.224.6134-fax
icgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance ' I
Address: 212 /n A►i��� ' Permit Number: E31 `CC)Q- [ "�-y
I Z
Contractor/Agency:(,a or o De . Equipment Replaced: /i(J
Natural Conditions: Pass ✓ Fail Date Tested 5— % ^ f
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass V Fail Date Tested 9— ! — 4
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
Address:
Contractor/Agency: _
Natural Conditions:
l (Failed
Worst Case Con/tit
Combustion Safety Test
Replacement of ura
Pass Fail
requires cor coons until
information:
(Failed teso
Date
Compliance Form
I Draft Appliance
Permit
Equipment
signature
tat I am the leo 1 owner ofVabove listed
has failed a Obrabustion Sdffety Test under
Owner's Name
Owner's Signal
test
that my
(One form submitted tgAuilding Services deportmeiX, duplicate form given to property owner)