HomeMy WebLinkAbout4602 Morning Dove Ct - Special Inspections/Combustion Safety - 12/27/2013FROM :NCR FAX NO. :9702299983 Feb. 03 2014 01:41PM P1/2
Planning, Development & Transportation Services
Community Development & Neighborhood 5ervicas
Qrt allies P0.8ox5800�BoAvernie
Fort Collins, CO 80522.0580
970A18.2740
970224.8194- fax
tcgov cam
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses I,
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Address: -1 ' 4L Permit Number:
Approved Agency:
I hereby attest that T have been trained as an Approved Agency and have perforrned the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012.
Technician Name (print): Company
Technician Signature:
-�........': --- -- Date-�__�L...���
Appliance Tested:�-
Appliance Replaced: t-n COAL Q . W ,, .-b^
Worst Case Conditions:
Spillage Duration (in seconds): 3_ Carbon Monoxide (parts per million):
Pass ✓ Fail Date Tested: a a7 )>LC � 0 1,1--
Natural Conditions:
Spillage Duration (in seconds): ?W Carbon Monoxide (parts per million):
Pass te'� Fail _,,., Date Tested: a-f pre- .Doo1-%
(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 Signature
CST: repiacem endnamrai-draft/4.25.12
Late