HomeMy WebLinkAbout612 BALSAM LN - SPECIAL INSPECTIONS - 4/21/2012CI}� Of Community Development and
Neighborhood Services
Fort Collinsrth College Avenue
P.O.P.
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance �qQ�
Address: �o/d �.c Permit Number: �10�/0, 9116 7
Contractor/Agency: Equipment Replaced: �y�
Natural Conditions: Pass '' Fail Date Tested y �� —
(Failed test requires corrections until Natural Conditions test passes)
Worst Case Conditions: Pass r Fail Date Tested yA'ai/ /a2
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