HomeMy WebLinkAbout2714 Rawahs Ct - Special Inspections/Combustion Safety - 01/30/2014Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
rt'Collins Box580
Fort Collins, CO 80522.0580
"£ 970..2740
970.224224.6134-fax
fcgov. com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address:S 04- Permit Number: A &DOS�
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 i
Technician Signati
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts er million):
Date Tested:
Natural Conditions:
Spillage Duration (in seconds): C70 Carbon Monoxide (p rts p r million):
Pass Fail Date Tested: tJ /
(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