HomeMy WebLinkAbout4219 Cape Cod Cir - Special Inspections/Combustion Safety - 06/05/2013Clt of Community Development
Y<` 281 N. College Ave.
6rt Collins PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: TZ/% /HOC �O/� �c Permit #: 413a� 4 �V—
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print): 4-1 Company pn/ D/Avis Li V
Technician Signature: J Date
Appliance Tested: ` og?11'r1 mF, q7%
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): _ Carbon Monoxide/(parts per million):
Pass J,� Fail Date Tested: p S 3
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections 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 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
CST: replacement/natural-draft/4.25.12
Date