HomeMy WebLinkAbout4238 STONERIDGE DR - SPECIAL INSPECTIONS - 5/17/201206/13/2012 03:38 9702263637 R&H HEATING PAGE 02
Planning, Development & Transportation Services
Community Development & Neigtiborhood SeeWCas
cjty of 281 Nanh College Avenue
F6 rt 50
Collins Fort Colli sa CO 80522.0680
••// 970.416.27A0
970.224.6134- fox
fcgovGam
Combustion Safety Test Compliance Foam
Replacement of Natural Draft Appliance
Address: Sf Permit Number-2120AU
Contractor/Agency: Equipment Replaced: 052
Natural Conditions: Pass )_ Fail Date Tested _ J�'1%' / —
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass _X Fail Date Tested
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 aclmowledgc that my
appliance has failed a Combustion Safety Test under worst -case conditions.
Owner's Name (print) 44) dt^d IA 4. eL
Owner's Signature Date _