HomeMy WebLinkAbout1111 Kirkwood Dr - Special Inspections/Combustion Safety - 03/14/2013970-22"134
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01:50:51 p.m. OS-14-2012 III
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PIWMing, De"topmot & Trans on Swim
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21H Avemis
P.O. -60
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9M.M4.0134, fax
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Combusdou Safety Te!i-,f -CompUan ce Form
RePIRCOMMt OfNaftral Dn& Appliances in Existing Houses
Addr--T-ss: I It I hel:
Pell
ApprovedAgency:
'I hereby aft% that I bm bmm ft*Aed as an Approved Ag=y and have perfimcd the following
COmbwtwu Safety Tel nia=rdance with FortCallms Combustm Maly Test Guide
Vemian 5. FebmcW 2DII
TechaidauName (printy, Stw� Sck12:5ft7�K COMPMy., O'n Oj N\O O\% A'k r
Teennieim.Signature:
Appli5maTeaed: Wft-r.er� A EnT &L-
A.1pplianceReplaced: Wf1,TZ(t- At^jt/L,
Worst Case Conditions:
Spillage Duratior, Cm seconds): CaTijea Mcw7ide (parts Oei mUlim):
Pass Fail E-lq-13
Na�sl Conditions.
rpii Dura!ian (m stcauft 2,0 *,n rJuc-
Pis FaR
Date Tested:
(Far7ed tat rqvbw mraVom Wad ft -q pa%* w wder N&WW Can&6m)
Tar b'deian's reconunmdations to omed tested gc?jjance failure:
Fou"'ed WOst Can Conditions:
I ceftfifyUmt I mn the legal owner of tie above liSted 73M@Mty aid hereby ackwwlWge ftt myWlimm
has failed a- COmbusfian Safety T,--j mdtx worst- -,sx Lo-adifiors. I acknowledge that I have, received a
combLsfim appliance aafety iffb=afion.eheet,
Owner's .Name (print)
0 --r's S, wn, ignature
Date-