HomeMy WebLinkAbout1225 W Prospect Rd - Special Inspections/Combustion Safety - 04/17/2014Combustion Safety Test Compliance Form '
Replacement of Natural Draft Appliance
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Address: /��� Cam/ Q�d���G'(j ,Q/�Nuritber:
Contractor/Agency: ZZ,�2� Equipment Replaced: /v e±*
Natural Conditions: Pass ✓ Fail Date Tested /P
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass Fail Date Tested
Failed appliance information:
(Failed test requires owner's signature acknowledging results.)
I certify that 1 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. t
Owner's
Owner's
(One form submitted to Building Services department; duplicate form given to property owner)
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