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City of I � Community Development & Neighborhood Services
Fort Collins 281 N College Ave; P.O. Box 580; Fort Collins, CO 80522-0580
-`' Phone: 970 221 6760 FAX: 970 224 6134
Field Verification Form
Job Site I \ FCon-�— i V it\ Permit No.
Company Name P�yy\5 PIUYA6nh IL\cCity of Ft Collins Lic# * S-3
Replacement of Sewer line approx. ft. (100 ft. maximum)
Replacement of Water line approx. ft. (100 ft. maximum)
X Add Replace gas line approx. ft. ( 50 ft. maximum)
Materials used:
Tested at 10 Lbs. for 60 minutes
Installer Name (print) kct-S
Installer Signature L\
r.
Date —' I
V\