HomeMy WebLinkAbout625 S WHITCOMB ST - SPECIAL INSPECTIONS - 10/16/2012Planning, Development & Transportation Services
City�1 Community Development S Neighborhood services
7 1 281 North College Avenue
/�F�ort Collins Fort Collins, CO 80522.0580
/ ` 970.224.2740
1n� 970.224.6134-fax
kgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: 6'v5 Ljki4&v%�L S+- Permit Number:
Contractor/Agency: PI,,�6-a Equipment Replaced: 4,ri NG �
Natural Conditions: Pass Fail Date Tested
(Failed test requires corrections until Natural Conditions,test.passes)
Worst Case Conditions: Pass -L Fail Date Tested o u' t z
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
Combustion Safety Test Compliance Form
Replacement of Natural. Draft Appliance
1 �w•twgci1.►+�� p4rw:�:�
Address: 6IS I�ijcarwb S+ Permit Number:
Contractor/Agency: tz.;ja&I r:, PIuW4,;'s. Equipment Replaced: 40e 'V4 W ' k&40,-
Natural Conditions: Pass Fail Date Tested
(Failed test requires corrections until Natural Conditions test passes)
Worst Case Conditions: Pass Fail Date Tested to t(. !z
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
IM
(one form submitted to Building Services department; duplicate form given to property owner)