HomeMy WebLinkAbout1512 Kirkwood Dr - Special Inspections/Combustion Safety - 06/24/2014City of
Fort Collins
Replacement
Address:
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
Icgov. com
lion Safety Test Compliance Form
'Natural Draft Appliances in Existing Houses
Approved Agency:
Technician Name (print): U/I, 6�
Technician Signature:
Permit Number:
Company
Date �4%� U/41
Appliance Tested:
Appliance Replaced: r n CA— 2
Worst Case Conditions: u
Spillage Duration (in seconds): I Carbon Monoxide (parts per million):
Pass .C?/— Fail Date Tested:
(Failed test req ices owner'.v signature acknowledging results)
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test.requires corrections until test passes under Natural Conditions.)
Technician's recommendations o correct tested appliance failure:
I certify that I am the legal own r 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 ap liance safety information sheet.
z
Owner's Name (print)
Owner's Signature
Date