HomeMy WebLinkAbout1312 Tarryton Dr - Special Inspections/Combustion Safety - 07/01/2013City of Community Development
281 Fort Collins N. College Ave.
PO
PO Box 580
F
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: ��j12 P�I�tZ �� Permit #: 1'30 3ZoZ
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): Company
Technician Signature: Date 77— (-l3
Appliance Tested:
Appliance Replaced:
Worst Case Conditions: j
Spillage Duration (in seconds):
Pass �?6 Fail
Natural Conditions: n
Spillage Duration (in seconds): 1t2_c�
Pass X�, Fail
Carbon Monoxide (parts per million):
Date Tested: �7-- (- 13_
Carbon Monoxide (parts per million)
Date Tested:
Z �Dw--
1 C) 14)rr,
(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) n`
Owner's Signature V o-
CST:replacement/natural-drafd4.25.12
LQ_l, Mai
Date 101 1 1 'j