HomeMy WebLinkAbout807 Marble Dr - Special Inspections/Combustion Safety - 03/01/2013r
Planning, Development & Transportation Services
city Of Community Development & Neighborhood Services
281 North College Avenue
Fort Collins Fort Colli s8 CO 80522.0580
/ r 970.416.2740
970.224.6134-fax
fcgov. com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: Permit Number: 61 ;ZO 3 j S 3
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012. nn rY\ _ Co Ir6
Technician Name (print): ry-es ompany L e� �� �•v�,
Technician Signature:. Date
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): O Carbon Monoxide (parts per million): /3
Pass _.,V Fail Date Tested: 3-1 -13
Natural Conditions:
Spillage Duration (in seconds): _0 Carbon Monoxide (parts per million): $
Pass _,4V Fail Date Tested: 3-1-3
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
no U. ovt.i rer- 4- 5ww key
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 Date
CST:replacement/natural-draft/4.25.12