HomeMy WebLinkAbout2514 Phantom Creek Ct - Special Inspections/Combustion Safety - 01/27/2014F6rt
Clt Collins Community Development
OI 281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: c� / �/ �l a ,, (/� ,/�!� Permit #: S Z V6V-),?
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
i
Technician Name
Technician Signab
Appliance Tested:
Appliance Replaced
4
Worst Case Conditions:
Spillage Duration (in seconds):
Pass i/ Fail
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
Company t
Date
Carbon Monoxide rts pe million):
Date Tested I
Carbon Monoxide (parts per million):
Date Tested:
(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
C ST: repl acement/natural-draft/4.2 5.12
Date