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HomeMy WebLinkAbout3403 Long Creek Dr - Special Inspections/Combustion Safety - 07/31/2014Planning, Development & Transportation Services Community Development 3 Neighborhood services City/ of 281 North College Avenue 0��. Collins P.O. Box580 Fort Collins, CO 80522.0580 970.418.2740 970.224.8134-f8x fogov.corn Combustion Safety Test Compliance Form Replacement of Natural Draft Appliances in Existing Houses Address: ©3 l-0r25 C� L b r. Permit Number: �/ Approved Agency: Technician Name (print): Technician Signature: Appliance Tested: _ Appliance Replaced: Worst Case Conditions: Company Date 7 31 I Spillage Duration (in seconds): Carbon Monoxide (parts per million): Pass Fail Date Tested: (Failed test requires owner's signature acknowledging results.) Natural. Conditions: j 6 Spillage Duration (inrsonds): 6o Carbon Monoxide (parts per million): PassFail Date Tested: 7 3� (Failed test requires corrections until test passes under Natural Conditions.) 1. Technician's.recommendations to correct tested appliance failure: 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) CL a rj CAR Owner's Signature Date 0 Zn