HomeMy WebLinkAboutDefered Inspection FormCOLORADO
Department of Local Affairs
❑Iviston oT Housing
Building Department Representitive Printed Name
Building Department Representitive Signature
Title C vlt a
Date 6 - 9
Accept / Defer Inspection
/11
If applicable:
Fire Safety Official Printed
Fire Safety Official Signature
JULY 2023
Contact email: oc- x3 �6kiItzruw%co.
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Contact email: —
Is a fire protection system required? (check one) Required Not Required
If required, the inspection is to be performed by (check one):
Fire Department: (NAME) —
OR
Colorado Division of Fire Prevention Et Control
Manufacturer's Authorized Quality Assurance Representative
Printed Name Ken Brower
Manufacturer's Authorized Quality Assurance Representative
Signature KeIA. BroAu —Date 01 /09/2025
Contact email: ken. brower@cavco.com
If the inspection has been deferred and the manufacturer elects to utilize an Approved Third Party
Agency to inspect the "OC" items on behalf of DOH, please sign and date below.
Approved Third Party Agent Printed Name Mike Faller
Approved Third Party Agent Signature Adoa, 97a&,°` _Date 01/09/2025
Contact email: mfaller@icc-nta.org
Governor Jared S. Polis I Rick M. Garcia, Executive Director I Alison George, Division Director
t _a
1313 Sherman St., Room 320, Denver, Co 80203 P 303.864.7810 F 303.864.7857 TDD/TTY 303.864.7758 www.dola.co[orado.gov :Z
Strengthening Colorado Communities
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EQUAL HOUSING
OPPORTUNITY