HomeMy WebLinkAbout5700 Sandbar Ct - Special Inspections/Combustion Safety - 03/08/2014FROM :NCA
FAX NO. :9702299983 Mar. 11 2014 09:30AM P3/10
City of
Fort Cottins
Planning, Development & Transportation Services
Community Development 8 Nelphbodmd Sorvtce6
281 North College Avenue
P.O. Box 680
Fort COMM CO 80522.0680
970A16.2740
970.224.6134-tax
rcgov.tam
Combustion Safety Test Compliance Form
Replacement of/Natural Draft Appliances in Existing Houses
Address: 5 % b(3 (4 _ Peimit Number: — w-u4
Approved Agency:
I hereby attest that I have buenl trained as an Approved Agency and have performed the following
Combustion Safely Test in accordance with Fort Collins Combustion Safety'fcst Guide
Version 5, February 2012.
Technician Name (print): Z u 64.a-� K0 ( -Company lea
Technician Signature:�'^"~� bate J= �y
Appliance Tested:
Appliance Replaced:
Worst Case Conditions: nq
Spillage Duration (in seconds); i; / Carbon Monoxide (parts per million):
Pass Fail _ Date Tested:
Natural Conditions:
Spillage Duration (in seconds): _
.Pass Fai I
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural Condidons.)
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 1 have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
C:ST:rcplaccment/natural-draft/4.25.12
Date