HomeMy WebLinkAbout824 Benthaven St - Special Inspections/Combustion Safety - 03/30/201317
City Community Development
o(f Collins N CollegeAve.
POPO Box 580
F6rt
Fort Collins, CO 80522
970.416.2740
970.224.6134(fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: tgo?y Ze-l� -T, <57' Permit #:
Approved 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): /�7 idoro& Company �Jo.r%m��/� ,
Technician Signature: Date 3- 3eq— a �J
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass � Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): _ Carbon Monoxide (parts per million):
Pass ) Fail Date Tested:
M
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
1 o i- e_
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