HomeMy WebLinkAbout1225 Paragon Pl - Special Inspections/Field Verification - 03/26/2012Mar 27 12 09:53a R & H Heating & fair Condi 9702263637
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Combustion Safety Pest Compliance Form
Replacement of Natural Draft Appliance
Community Development and
Neighborhood Services
281 North Collego Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416,2740
970.224.6134- fax
rcgov. coin/dc vctapment
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Address: -I-Y� r n .�,� ! � Permit Number:
Contractor/Agency: o f /(_z j Trw._ r/) i.._ Fquipmcnt Replaced:
Natural Conditions: Pass X, Fail Date Tested _ 9 ' 16 - i „^
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass Fail Date Tested % r! ` 1 1
'Failed appliance information: k, kZ u r4r t,, d'C�
(Failed test requires olvner'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 Qworst-case conditions.
Owner's Name (print) es % �' �� I '`` 1 T- �t
C
owner'$ Signature Tate