HomeMy WebLinkAbout600 Saint Michaels Dr - Special Inspections/Combustion Safety - 01/02/2014FROM :NCR FAX NO. :9702299ge3 Feb. 03 2014 01:41PM P2/2
Planning, Development & Transportation Services
i t Q� Community Development & Neighborhood Services
!81 North College A"fte
�F} Collinsns P.O.eoxb80
4 Fort Collins, CO 80522.0580
970.416.2740
970224.6134- fax
lcgovxam
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance% in Existing Houses "U
Address: _�� f e �� Permit Number: �Iy d J
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
Version 5, February 2012.
Technician Name (print): se 0- 1�d�. •z,,, Company 4,�e14-
Technician Signature: /T - Date / " 2 zy
Appliance Tested: /� ,..., ii�a•
Appliance Replaced:
PPL�lrB �•.�G
Worst Case Conditions;
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass •� Fail slate Tested:
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
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:
T 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 vafely information sheet.
Owner's Name (print)
Owner's Signature
CS T: reptacem ent/natural-draft/4.25.12
Date
st