HomeMy WebLinkAbout820 Napa Valley Rd - Special Inspections/Field Verification - 11/07/2012City Community Development
F6rtOI Collins PO College Ave.
PO Boo x 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/d`ove/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: sac) Q i"Qc J �`c V , , Permit #:
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 (
Technician Signati
Appliance Tested:
Appliance Replaced:
I
Worst Case Conditions:
Spillage Duration (in seconds): _ Carbon Monoxide (parts per million): 0 >�
Pass k Fail
Natural Conditions:
Date Tested: 11— -? - � D,
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:
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
Date , r 6v' 12
CST:replacement/natural-drafCt//4.25.12
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