HomeMy WebLinkAbout1636 Collindale Dr - Special Inspections/Field Verification - 10/05/2012City Of
Fort 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
fcgov. oom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 1 (w,3 � ` � r /1, r,4 4 Dr Permit Number: Blaoaqo
Approved Agency:
Technician Name (print) -
Company
Technician Signature: Date
Appliance Tested: ff?o �l
Appliance Replaced: f7 7,
Worst Case Conditions:
Spillage Duration (in seconds): 2-
Pass K Fail
Carbon Monoxide (parts per million): Z 3
Date Tested: Z-( 4 - I Z
(Failed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds):
Pass X Fail
Carbon Monoxide (parts per million): j
Date Tested: 2-I4-IZ
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
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
Date
6'd 9Z£9£6bOL6
6ulgwnld u4eH e£0:l l Zl 90100