HomeMy WebLinkAbout1632 Foxhall Ct - Special Inspections/Combustion Safety - 05/08/2014Planning, Development & Transportation Services
Cit)<#� t�nU Community Development & Neighborhood Services
y � 281 North College Avenue
wort Collins P.O Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
rcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: j 632,�o—)ck.11 CF , Permit Number:1914 012 SI
Contractor/Agency: Rr�a 4 Equipment Replaced: a :t?2El 06 "4w b6lto
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Natural Conditions: Pass Fail Date Tested
( 7ailed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass Fail Date Tested S'�T//4
Failed appliance information:
(mailed test requires Givner'S signature ack-noi 1e61gino resulL,.)
I certify that I am the legal owner of the above listed property and hereby acknowledge that my
appliance has4kAetk a Combustion Safety Test under worst -case conditions.
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Owner's Name (
Owner's Signatu