HomeMy WebLinkAbout2634 Leisure Dr - Special Inspections/Combustion Safety - 02/13/2013,CityOf Community Development
y 281 N. College Ave.
Fort Collins PO Box 580
� . Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
kgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: Q (e 3 q Le, isUifc. Permit #: e (360 Ll1(
Approved Agency: (3 t3 60 `llt Z
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): Ka oq 6ova Company Prow (�[uw,btyka 444 \A4
Technician Signature: LA ��— Date 2113 1
Appliance Tested:
r
Appliance Replaced:
Worst Case Conditions: N/A"
Spillage Duration (in seconds):
Pass Fail
Natural Conditions:
Carbon Monoxide (parts per million):
Date Tested:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): 0
Pass Fail Date Tested: Z:: 3i 3
(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
CST:replacement/natural-draft/4.25.12
Date