HomeMy WebLinkAbout1524 Sam Houston Cir - Special Inspections/Field Verification - 02/23/2012Community Development and
Fort
of Neighborhood Services
Collinsth College Avenue
P.O.P.
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
tcgov.cov.comIde/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: _ �Sa?y �"J t/6ys�a G'r Permit Number: BI-2,06!4
Contractor/Agency: 4gylNf CZ_ Equipment Replaced: firl4,
Natural Conditions: Pass Fail Date Tested o71,2
(Failed test requires corrections until Natural Conditions test passes).
Worst Case Conditions: Pass 6� Fail Date Tested 2 Z
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)
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Owner's Signature ------- r Date �—
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