HomeMy WebLinkAbout1456 Edgewood Ct - Special Inspections/Field Verification - 03/26/2012Rues, LLC 970-61MO74 p.2
rnnl lJ/LU1L/ttSU lt'JO At ueveiopmem review Cxd tic, JjU''L4-b!34 '. UU4
Planning, Development & Transportation Services
rCity of Community Development & Neighborhood Services
281 North 0OegaAvenue
P.C.P.Box 580
Fart CNgns. CO 805ZZ0580
970.4f 6.2740
970.224.6134- fax
legouaom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: i r Q uv"t3,� c� C� . Pertnit Number: e>1 2-
Contractor/Agency: rk t c.� k (��. (rt �a . Equipment Replaced: i )�� i�•W -
Natural Conditions: Pass Fail Date Tested 3 - Z 6 _ / Z--•
(Failed Natural Conditions test requires corrections until Natural Conditions test passes)
Worst Case Conditions: Pass Fail /K Date Tested
Failed appliance information:
(Failed Worst Case test requires owner's signature acku)wledging reserlrs.)
I certify that I am the legal owner of the above listed property and hereby acknowledge that my
appliance bus failed a Combustion Safety Test under worst ease conditions.
Owner's Name (print) r! u /L
Owner's Signature
0