HomeMy WebLinkAbout1907 Valley Forge Ave - Special Inspections/Combustion Safety - 02/21/2014FROM :NCR
FAX NO. :9702299983 Mar. 18 2014 01:25PM P7/8
City of
Fort Coles
Planning, Development & Transportation Services
Community Development 8 NetOhba tood 8ervkee
281 North Collepe Avenue
P.O. nou 680
Fort Coptne, CO 80522.0580
870.418.2r40
070.224.8134- fax
Iqw com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses h �-y-
Address: f 98 Z j a Emy /f t ✓P . Permit Number: V w 1
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Wide
Version 5, February 2012. Q
Technician Name (print): g� ....Company Pot. 1�Y�� (� (�b J A ✓
Technician Signature:`" Date..,.J�/
ApplianceTested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in secon Carbon Monoxide ( s pe million): 1
Pass Fail Date Tested: ?� � �
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
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.S'1': rcplacemcnt/natural-draft/4.25.12
Date