HomeMy WebLinkAbout5922 Venus Ave - Special Inspections/Field Verification - 07/17/2012City of
®rt Collins
-.
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins. CO 80522.0580
970.416.2740
970.224.6134-fax
tcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 5 9 a a ¢ n to S Permit Number: 0-W10 LA 19 S
Approved Agency:
Technician Name (print): ovi 1 S '.�blan Company L
Technician Signature: to Date
Appliance Tested: W
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): Q ce Carbon Monoxide (parts per million): C o&,) L-tZr 1X01t2ICy7'
Pass c Fail Date Tested: - / i - / Z
(Failed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
I certify that 1 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. I acknowledge that
I have received a combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature __ Date