HomeMy WebLinkAbout4115 Cedargate Ct - Special Inspections/Combustion Safety - 09/04/2013FROM :NCR FAX NO. :9702299ge3 Nov. 07 2012 02:16PM P1/1
Planning, Development & Transportation Services
4l O Community Development & Neighborhood Bervices
261 NOrlh College Avenue
P.O. Sox 680
F�rt Collins
Fort Collins, CO 80622.0680
r 970.416,2740
970.224.6134• tax
/agovxom
Combustion Safety Test Compliance Form
Replacement of Natural Draft
//Appliances in Existing Houses
Address: _6'L.Permit Number:
Approved Agency:
I hereby attest that 1 have boon trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, rebmary 2012.
Technician. Name (print): f?o 6 w ( ( -A,,,�_ . company— 1`0 C
Technician Signature:
Appliance Tested: &14ze � ftza4",
Appliance Replaced: _ ti'hl�tLiC.C.r-
Date
Worst Case Conditions:
Spillage Duration (in seconds): _��,.._ Carbon Monoxide (parts per million): p
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds):
Pays Fail
Carbon. Monoxide (parts per .mil lion):
Date Tested:
(Failed test requires corrections until test passes under.lVatural Conditions.)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
1 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 Date
CST:rcplaccment/natural-draft/4.25.12