HomeMy WebLinkAbout901 Arbor Ave - Special Inspections/Combustion Safety - 05/13/2013FROM :NCR
FAX NO. :9702299983 1 May. 29 2012 02:28PM P2i3
FCity Of
ort Collins
Planning, Development & Transportation Services
Community Development & Neighborhood Services
201 North College Avenue
P,o, Box 580
Fort Collins, CO 80622.0580
970.416.2740
870,224.6134-fax
fcyov. cam
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: _�&4 AeAoll Permit Number:
Approved Agency:
J. hereby Latest 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_ /
Technician Name (print): _ c,e? Company
Technician Signature; Date a rg
Appliance Tested: - •� __
Appliance Replaced: _ P_U t �-,, imq 7z�?2
Worst Case Conditions:
Spillage Duration (in seconds): Carbon .Monoxide (parts per million):
Pass ____L Hail
Natural Condition's:
Spillage Duration (in. seconds): _
Date Tested:
Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test requires correclinm 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 atx)vc listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst -case conditions. 1 acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature _ ... Date
CST;replacement/nat14ral-draft/4.25.12