HomeMy WebLinkAbout4512 Maxwell Dr - Special Inspections/Field Verification - 02/15/2012FortColtins
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Community Development and
Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins. CO 80522.0580
970.416.2740
970.224.6134-fax
tcgov.com/de velopment
Address: 51�_ q,��\ 1C Permit Number: Z\'amiz3
Contractor/Agency:=��� . , Y Equipment Replaced:
Natural Conditions: Pass Fail Date Tested 4A\5\\Gk
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass L Fail Date Tested-ANA\a.
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
Z00/Z00'd £6£N lZ:ll ZIOZ/EL/£0 £LOZ£6bOLS JIy XaiTPA a,lpn0d:w0JJ