HomeMy WebLinkAbout308 E Swallow Rd - Special Inspections/Combustion Safety - 09/18/2013Planning, Development & Transportation Services
r Community Development & Neighborhood Services
City OI 28, North College Avenue
F �� Co[tins
P.O. Box
OFort Collins,Cox 5CO 80522.0580
970..2740
870.224224.8134-fax
hgovcom
Combustion Safety Test Compliance Form
Replacement of Natural DraftAppliances in Existing Ho s 30 � ^
Address: 'SOS CJ wlPermit Number:
Approved Agency: r
Technician Name (print): M �-S O �V Company �AIAH � �� U/�I QI /v �i ��� b
Technician Signature: —# a4!(7h aDate , ��T=l 20
Appliance Tested: (� /�-� d±�� 1X'
Appliance Replaced: ,,,A (W HfA RR
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):, 111114
Pass Fail _. Date Tested: 911AI20'1 3
(Failed test requires owner's signature acknowledging results.)
Natural. Conditions:
Spillage Duration (in seconds): -3 0 Carbon Monoxide (parts per million):
Pass x Fail Date Tested: 911$/ 2 0 13
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
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) 1%- 'vv� 0-
Owner's Signature Date