HomeMy WebLinkAbout1838 Indian Hills Cir - Special Inspections/Combustion Safety - 05/20/201305/21/2013 14:02 FAX
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Fort Collins
Planning, Development & Transportation Services .
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
1' ort Collins, CO 80522.080
910.416.2740
970.224.6134-fax
lcgovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing mouses
Address: J�!�ef �." w Permit Number: Oi �
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,§, February 2012.
Technician Name (print): 'GhL v�Iil�npanY CvLCs ° J�J �G��y i,•�
Technician Signature: Date k 'kO- Z'
Appliance Tested: /,Vol _Ai'L=✓��„G�2
1- R 1 d 1
App lance ep ace .
Worst Case Conditions:
Spillage Duration (in seconds): _ _ Carbon Monoxide (parts per million): —�
Pass 1/ Fail Date Tested: S �`
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until rest Lasses 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 applianc e.safety information sheet.
Owner's Name (print)
Owner's Signature
CST:replacement/natural-draft/4.25.12
Date