HomeMy WebLinkAbout509 Cornell Ave - Special Inspections/Combustion Safety - 01/09/2014C8� OAS Community Development
Fort Collins 281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/d`eve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: SyCI CiCi 1i7�Gf t/ i Permit #: /� / v 6 / 2 o
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Sa(fety� Test Guide Version 5, February
�2012.
Technician Name (print): � 1,WPI � l i'u� Company
Technician Signature: �II Date
Appliance Tested:v (�
Appliance Replaced: ; I ! t16
Worst Case Conditions:
Spillage Duration (in seconds): 2 Carbon Monoxide (parts per million):
Pass -`� Fail Date Tested: TI —/ I
Natural Conditions: ^y
Spillage Duration (in seconds): Carbon Monoxide (parts per million): KJ
Passim Fail Date Tested: I
(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 1 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 Signaturt Date
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