HomeMy WebLinkAbout3203 Barn Swallow Dr - Special Inspections/Field Verification - 11/19/2012Community Development
City ®f 281 N. College Ave.
Fort Goblins PaBOX Sau
Fort Collins, CO 80522
970.418.2740
970.224,6134 {fax)
fcgov. corWdevelopment
Combustion Safety Test Compliance Form.
Replacement of Natural Draft Appliances in Exdsting doused
Address: 2 l7_ _�j�� s f,fc�% c�.. Ate_ _ Permit#:(Jt/�
Approves. 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): -t47, '��_ Company Ddi6g N/z:c ie r
Technician Signature:: IJ A7-Date Il
Appliance Tested:
Appliance Replacee:
Worst Case Cojidibons�
Spillage Duration (in seconds): /. 5 Carbon Monoxide (parts per million): --
Pass (1 Pail Date Tested: 11,11711Z
Natural Condit ons:
Spillage .lhtration (in seconds): /_ d Carbon Monoxide (parts per trillion): ! (o
pail Date Tested: �41 12
(Availed test requires corrections until test passes under Natural Conditions)
Technician's recotmmenziadoxis to correct tested appliance failure:
Failed Worst Case Conditions:
I certify tha: I am tfic legal owner of the above listed property and hereby acknowledge that my appliance
has faffed a Combustion Safety Teat under worst -case conditions. I acknowledge that I have received a
combustion applance safety information sheet.
Owner's Name (print)
Owner's Signature
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Date