HomeMy WebLinkAbout208 S Shields St - Special Inspections/Combustion Safety - 01/23/201301/23/2013 17:02 FAX
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Fort Collins
Planning, Development & 1-ransportation Services
Community Dovelopmant & Neighborhood Services
201 North Coltcge Avanoo
P.U. Box 500
Fon Collins, 00 60022.0580
970.416,2740
970,224.6134-fax
frgov Com
Combustion Safetv Test Compliance Form
Replacement of Natural Draft Appliances in Existing houses
Address: P 0 0 514 I 0 U)=C permit Number: e1300 9L4-24 .
Approved Agency:
1 hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Tort Collins Combustion Safety Test Guide
Version 5, February 2012.
Tint )ls &/ tL/ L 2 t. Company �tJ� r� 6o1ciPl%D
Technician Name (print):
Technician Signature: -""�y Date
Appliance Tested:4e�7`.fzc ati�;,11/'
Appliance Replaced:
Worst Case Conditions:
USpillage Duration (in seconds): ! _Carbon Monoxide (parts per million):
Pass _,LZ Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
pis rail Date Tested:
(Failed rest 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
CST:replacement/natural-draft/4.25.12
Date