HomeMy WebLinkAbout3813 Granite Ct - Special Inspections/Combustion Safety - 07/19/2013City of Community Development
Fort Collins 281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
kgo v. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 3 �?/? 61rat ✓1 rTe. C4 Permit #: L51- Otg
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):"%//'rt Vl a r'T f ►,...Company A jPt.t ..,,, X ,4,'/
Technician Signature: __ �' Date r7l) % 13 i
Appliance Tested:rPeA tvt iek-
Appliance Replaced: /lit /'r'1 C., C f..
Worst Case Conditions:
Spillage Duration (in seconds):
Pass 4— Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested: 9 / / 9A
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-drafd4.25.12
Date