HomeMy WebLinkAbout5102 Stetson Creek Ct - Special Inspections/Combustion Safety - 03/15/2013CC 0 C�
Planning, Development & Transportation Services
City of Community Development & Neighborhood Services
Fort Collins 281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
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Address: / O2 S� s � � � �� `30 �tNr Permit Number:
Approved Agency:
Technician Name (print):
Technician Signature: _
Appliance Tested. -
Appliance Replaced:
Worst Case Conditions:
Company
Date
Spillage Duration (in seconds): . 03 Carbon Monoxide (parts per million):
Pass Fail Date Tested: 3 i C,
(Failed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds): . 9 D Carbon Monoxide (parts per million):
Pass V Fail Date Tested:
(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 (print)
Owner's Signature Date