HomeMy WebLinkAbout2960 W Stuart St - Special Inspections/Combustion Safety - 03/28/2013 (2)Planning, Development & Transportation Services
Community Development & Neighborhood Services
City of
281
ort Collins rth College Avenue
P.O.P.
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 'aci E,(-) Q �� .a o < Y Permit Number:
Approved Agency:
Technician Name (print): �,.., Ya,,.k�..�, o Company
Technician Signatur Date 13
Appliance Tested: W'A' r I.X z A e l
Appliance Replaced: \_ ),. - r k-,Q AE t
Worst Case Conditions:
Spillage Duration (in seconds): I sec. Carbon Monoxide (parts per million):r ' �1u�
Pass Fail Date Tested:
(Failed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass _ Fail Date Tested: 3 -X%-\�
(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) V�SS 1C0. Lb`ei(0.j�
Owner's Signature Xk A`� Date 3cs