HomeMy WebLinkAbout2300 Amherst St - Special Inspections/Combustion Safety - 12/13/2013City of Community Development
Collins 281 egeAve.
PO Boxox58580
F6rt
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:,.,�M �j�_ y5� SSG Permit
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): T' v Company Z41"1' -e j�, ��---
Technician Signature: ,a!-. E z h_ � Date
Appliance Tested: 7�U
Appliance Replaced: A4* f ZA1aZ9I
Worst Case Conditions:
Spillage Duration (in seconds)
Pass —1— Fail
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
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-draft/4.25.12
Date