HomeMy WebLinkAbout4050 Kingsley Ct - Special Inspections/Field Verification - 04/25/2012SEP-24-2012 12:36 From:Allen Service 970 484 4448 To:92246134 Paee:1�1
Planning, Development & Transportation Services
Cud ®d Community Davolopment 8 Neighborhood Services
Fort Collins ege Avenue
pod 8ox5 01 North 11O80522.05
Fort Colons, CO 80522.0580
970.416.2740
970.224,6134-tax
IWV.Com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses ,(� (�
Address: Qc (� %�j u G t; (.9 0 Permit Number:. `EW 109
Approved Agency:
-Technician Name (print): a .` Company c �.
Technician Signature: Date y F'
Appliance Vested: _14 K%
Appliance Replaced: t.t/
Worst Case Conditions:
Spillage Duration (in seconds): T �s�: Carbon Monoxide (parts per million):
Pass -, - Fail Date Tested: 6q-11- Z
(Failed test requires owner '.v signature acknowledging resulm)
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):_
Pass Fail Date Tested:
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
VW �-
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
1 have received a combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature Date