HomeMy WebLinkAbout808 Napa Valley Dr - Special Inspections/Combustion Safety - 02/01/2013Planning, Development & Transportation Services
of
Fort Collins
Address:
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 680
Fort Collins. CO 80522-0580
970.416.2740
970.224.6134- fax
fcgov.com
. Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
`' D<-
�' () 6, V /}„ e,\j_ Permit Number:
Approved Agency:
Technician Name (print)/✓®
Technician Signature:
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
4o- k-%n P-14
_ Date —a- l 1 3
Spillage Duration (in seconds): �_ Carbon Monoxide (parts per million): VvL
Pass Fail Date Tested:
(Failed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): -V
Pass _� Fail Date Tested: 0L
(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 (pri
Owner's Signature