HomeMy WebLinkAbout1200 Buttonwood Dr - Special Inspections/Combustion Safety - 08/27/2012City Community Development
Fort
t Collins 281 N. College Ave.
PO Box 580
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: /ZOd /3L��Owt-/o /�►_ �,LL Permit#: 5 12_0-45_1�S-3
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): I201c/ Lt s&oXompany Af/DY?&-s LLL
Technician Signature: ce.B417 F Date 5f2?7,- 2,4 !Z
Appliance Tested:10 f- LcrA'fer tl A— —
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds)
Pass IX Fail
Natural Conditions:
Spillage Duration (in seconds)
Pass �)( Fail
Carbon Monoxide (parts per million):
Date Tested:
Carbon Monoxide (parts per million):
Date Tested:
(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