HomeMy WebLinkAbout7502 Gold Hill Ct - Special Inspections/Combustion Safety - 06/18/2013Planning, Development & Transportation Services
City. Of CornrmaHty Devetopmert & Netgh6orhoW services
281 North
Collins Xt CO6 2en0
ue
970.416.2740
970.224.6134- fax
fagov com
Comtiwdon Safety Test Compliance Form
PaPbmment of Natural Draft Applianees in Existing Houses
Address: '� 5`G�z G'o%,/ /�/. // �o'U� f Petnit Number:
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have perforated the following
Combustion Safety Test in accordance with Fort Collins Ca nbustion Safety Test Guide
Version S, February 2012.
Technician Name (print): ,'c C LJi 1. Company , b er
Technician Signature: Date 4fi� /327
Appliance Tested: w�
Appliance Replaced: W&J,-,
Worst Case Conditions: Spillage Duration (m seconds): (a d Carbon Monoxide (parts per million): -_
Pass Fail Date Tested: C�i sr / z�, i
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested: / /
(Failed testregrwnc corrections withtestpacxses widerNawnd Conditions,)
Technician's recommendations to correct tom. apphance fffilure:
Failed Worst Case Conditions:
I certify that I am the legal owner of the above lined property and hereby aclmowledge that my appliance
has baled a Combustion Safety Test under worst -case oondWom, I aclmowledge that I have received a
combustionaPP yinforniationsheet.
Owner's Name (print) f%.C-- 4r/ �llP`c rr
owners signattzce_yttat:ko� l l�,+s�, e;�/ Date ze-9
CSTMT 415.12