HomeMy WebLinkAbout1049 Parkview Dr - Special Inspections/Combustion Safety - 06/20/2013i,
Planning, Development & Transportation Services
Port Colfilalm.
Community Development & Nelghbarhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgovc0m
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses 2 q
Address: 10ui;l PI'Y\f�tc'a a Permit Number.
Approved Agency:
Technician Name (print): Gl� ` "' Company c
Technician Signature: i l `�` Date
Appliance Tested: I �w }✓
Appliance Replaced:
PV
Worst Case Conditions:
Spillage Duration (in seconds):
Pass rJ Fail
Carbon Monoxide (parrs per million):
Date Tested:
(Failed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
CJ
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
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) 1 "'440 4- a^-o
Owner's Signature Z��7Z Ap Date U %
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