HomeMy WebLinkAbout1115 Saint Croix Pl - Special Inspections/Combustion Safety - 06/13/2013Jul,22. 2013 3:39PM 9704844448 ALLEN PLUMBING&HTG
No•4266 P. 1/1
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Fort Collins
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-_- Replacement o
Address: % C /�L
Approved Agency: �
Technician Name (printt):y�
Technician Signatore:.C-&P%
Appliance Tested: f
Appliance Replaced: 164e_y�
Worst Case_ Conditions:._
- Spillage Ofiratioti (in seconds):_
Pass X To
(Failed test req,
Planning. Development & Transportation Services
Community Development & Nelghborhood services
281 North College Avenue
P.O. BOX 580
Fort Collins, CO $0522,0550
970,418.2740
970.224.8134-fax
fcgovcom
;ion Safety Test Compliance Form
Natural Draft Appliances in -Existing Douses —
i X Permit Number: T5 00
Company A�� n� f,..�el�i e e
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3; Carbon Monoxide (parts per rttllion):
Tres nwrrer's_signature-acknowledging-result,�.)-_--- _ _ ;� __ . • _. _
- Natural Conditions:
-- Spillage Duration (in seconds): -- .Carbon -Monoxide (parts per million): -
Pass Fail Date Tested:
- (huil�i!-tell requires c rrectlnns until test pasxes under Natural`Candltlrrns:) - -- _ - - _ -`
Technician's recommendations-tijo correct tested -appliance failure_
- -I certify tfiat I a`m the legal o
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appliance has failed'a Corxrbu
I have received a combustion
Owner's Name (print) 26
Owner's Signature- a
w
h r of the above -listed -property and hereby acknowledge that my- --
sti n Safety Test -under worst -case conditions...1 acknowledge_that- _ -
a liance safety information sheet.
Date=. 3
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