HomeMy WebLinkAbout1018 Tierra Ln - Special Inspections/Field Verification - 04/25/2012Community Development and
Cityof Neighborhood Services
7 281 North College Avenue
ort { ^ O ins PO Box580
v Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
kgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: IM8 INht IAA IPermit Number: ZjjZQ �-U-O pp
Contractor/Agency: `� 2 s Equipment Replaced: tf VV_rA&ee 90.
Natural Conditions: Pass V Fail Date Tested
(Failed test requires corrections until Natural Conditions test passes.
Worst Case Conditions: Pass (1lFail Date Tested al z5l 1 L
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