HomeMy WebLinkAbout1024 Mirrormere Cir - Special Inspections/Combustion Safety - 09/28/2012970-224-6134
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11:37i05a.m. 09-28-2012 1/1
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City, of Community Development
i 281 N. College Ave.
F&tColhns PO Box590
;i Fort Collins, CO 80622
j( 970.416.2740
0 970224.6134 (fax)
kgovcom/development
tf
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Douses
Address: Uil_. Permit'*
Approved Agency: I
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.
Technician Name (print): ; O L F Co parry Fitt SAM ki r 2 1 jKl I j
Technician Signature:
Appliance Tested:
Appliance Replaced:
Worst Case Conditions: `2
Spillage Duration (in seconds): 1
Pass -71'C Fail
Natural Conditions:
Date
Carbon Monoxide (parts per million):
Date Tested:
Spillage Duration (in seconds): Carbon Monoxide (parts per mullion):
Pass Fail 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. i
Owner's Name (print)
Owner's Signature Date
CST*.mplacementtnatumi-drafd4.25.12