HomeMy WebLinkAbout933 Glenloch Dr - Special Inspections/Field Verification - 09/08/2012City O� Community Development
Fort Collins 281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: g32) G /� vi h c)c- J�,[1 , Permit #: bIzu
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print): 'x) v c M u h? cc u Company .L R / 5Y PI-> l
Technician Signature: -DOL - 2?2a Date
Appliance Tested: L✓ /1 7 iz, C ,1i T>eg, -�-e / —
Appliance Replaced: t,J 6( � -Pgr -1 .e., —
Worst Case Conditions: x
Spillage Duration (in seccoonds): V Carbon Monoxide (parts per million):
Pass V Fail Date Tested: �- c�S ' ,
Natural Conditions:
Spillage Duration (in seconds): �SN Carbon Monoxide (parts per million):/"1 =
Pass Fail Date Tested:
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
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. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
C ST:replacement/natural-draft/4.25.12
Date