HomeMy WebLinkAbout1870 Indian Hills Cir - Special Inspections/Field Verification - 11/29/2012FROM :NCA
FAX NO. :9702299983 Dec. 07 2011 02:18PM P2/5
-City of
Fart Collins
Planning, Development & Transportation Services
Community Development 8 Neighborhood Services
281 North College Avenue
_ P.O. Box 580
Fort Collins, CO 60522.0580
970.416.2740
970.224,6134-fax
fogov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 170 7o 144%old—, Permit Number:
Approved Agency:
Technician Name (punt): %1[...... Attl company _1ve-1+
Technician Signature: G Date
Appliance Tested: _ W�
Appliance Replaced:.... ZA, l/ CSZ-
Worst Case Conditions:
Spillage Duration (in seconds):._ .3d Carbon Monoxide (parts per million): _
Pass _ Fail _ Date Tested: /1 -z�—
(F'ailed test requires owner's signature arkirmvledging results.)
Natural Conditions:
Spillage Duration (iri seconds)
Pass Fail
Carbon Monoxide (parts per tnillion):
Date Tested:
(Failed lest 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 -ease conditions. I acknowledge that
I have received a combustion appliance safety information sheet.
Owner's Name (print) _„
Owner's Signature Date ...