HomeMy WebLinkAbout1501 Luke St - Special Inspections/Combustion Safety - 03/01/2013City of Community Development
Fort Collins 281
F N. geAve.
PO Boxox580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: J .5--01 L"H e, ST- Permit #: ./9 /:3 O Q
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): Company
Technician Signature: Date
Appliance Tested:
Appliance Replaced:
t v� bV+V
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): U
Pass Fail Date Tested: —� —
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million)
Pass % Fail Date Tested:
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
4 30
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: rep] acement/natural-draft/4.25.12
Date