HomeMy WebLinkAbout4233 Stoney Creek Dr - Special Inspections/Field Verification - 02/13/2012Planning, Development & Transportation Services
City, of Community Development s Neighborhood Services
`� //►► 281 North College Avenue
Fort ( v ollinsC P.O. Box580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: 0,33 .S-ro raXbr Permit Number: 8 )�2 006 weo"
Contractor/Agency: 1,.)mrj_. "lne__�arvc'p_S Equipment Replaced:
Natural Conditions: Pass Fail Date Tested 2 r I i�— l2
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass _, Fail Date Tested o? --13- � 2
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