HomeMy WebLinkAbout2826 Stonehaven Dr - Special Inspections/Combustion Safety - 04/11/2014Clt Of Community Development
281 N. College Ave.
PO Box 580
Fort Collins
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: �� S�oi fie_ l��vc.0 �/' � CI�Permit #: �J I LI b I ?,
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.
Technician Name (print):
Technician Signature:
Appliance Tested:
Appliance Replaced:
'j-
Company
Date a- l I- 114
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): .�� Carbon Monoxide (parts per million):
Pass'Y Fail Date Tested:
f
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
�� �' fi, •� R��rnr
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
CST:replacement/natural-draft/4.25.12
Date