HomeMy WebLinkAbout501 Duke Ln - Special Inspections/Combustion Safety - 04/08/2014Planning, Development & Transportation Services
Ci O � is 281 North College Avenue
Community Development & Neigh1wrhood ServicesX 680
Fo� Collins Fort Collins, CO80522.0580
d 970AIS.2740
970.224.8134- fax
fogov.0om
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: ' �-Q I l4�2 LN • Permit Number. 5/ L/O
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 Guide
Version 5, February 2012.
Technician Name
Technician
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Date
Worst Case Conditions:
Spillage Duration (in seconds):_ Carbon Monoxide (parts per million):_
Pass _ Fail Date Tested: q I C-1 I IQ
Natural Conditions:
Spillage Duration (m seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test requires corrections unfil 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 Date
CST:replacemendnaturai-ira V425.12