HomeMy WebLinkAbout4427 Craig Dr - Special Inspections/Combustion Safety - 07/03/2014Community
F City of 281 N. College Aveopment
6rt Collins PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgo v. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 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): J /`c, o y' 14 Company cr,.A i C 9,7 ) el t- eo,4 i-✓v
Technician Signature: Date 713/
Appliance Tested: / 6✓a f-e v- 6 PC, �-r / a , iG /-✓r0 c, c e
Appliance Replaced: Ft/✓ v) A c- e-
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):_
Pass X Fail Date Tested: 7 /3/�/
Natural Conditions: /J
Spillage Duration (in seconds): '1 Carbon Monoxide (parts per million):
Pass Y Fail Date Tested:
(Failed testrequires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
it/ /.f-
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