HomeMy WebLinkAbout2420 Mathews St - Special Inspections/Combustion Safety - 11/25/2013Planning; Development &Transportation Services
�It O� Community Development & Neighborhood Services
F6rt Collins BOX58281 North 0aegeavenue
P.O.P O Box 580
Fort CoWrs, CO 80522.0580
970AIGM40
970224.6134-fax
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 2 / l �� { �/� Permit Number.
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
VersiR 5, February 2012.
Technician Name (print): .�ngpany ��R 1/ T� �� ' ti /� - r
Technician Signature: Date
Appliance Tested: 2alif-r en-- r-
Appliance Replaced: FUG Vq G e,
Worst Case Conditions: /
Spillage Duration (in seconds): Carbon Monoxide (palts per million):
Pass Fail Date Tested: Z
Natural Conditions:
Spillage Duration (m seconds):_ Carbon Monoxide (parts - er`million):
Pass Fail Date Tested: ZJ
(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
CSTaVlacement/natrual-draft(4.25.12
Date