HomeMy WebLinkAbout3342 Sunningdale Pl - Special Inspections/Combustion Safety - 04/15/2014Community Development
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CltyCo����� 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: x'c!`coIj4�.r>e P\ Permit #:
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): c kt.1c4 Company ageyq Cl
Technician Signature: Date q
Appliance Tested: _
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seccoo ds): _
Pass d Fail
Natural Conditions:
Carbon Monoxide (parts per million):
Date Tested: L/ i
Spillage Duration (in seconds): Carbon Monoxide (parts per million): _
Pass _z� Fail Date Tested: - V
(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
CST:replacement/natural-draft/4.25.12
Date — l -