HomeMy WebLinkAbout425 W Troutman Pkwy - Special Inspections/Combustion Safety - 05/05/2014.r
City of
Fort Collins
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
fcgov.com
. Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: UkV '—� Permit Number:
Approved Agency: �j �, , ��
Technician Name (print): dr ' L —L` ` S Company u�a �✓1� ! n �1(Cv+/UCJ
Date �S--
Technician Signature: _
Appliance Tested: A 961`i-� (. '�I _ `�I)V - I�W!;t `-'v f- d a
Appliance Replaced: (D L>
Worst Case Conditions: y� ��
Spillage Duration (in seconds): _ Carbon Monoxide (parts per million): 4gm ,.5
Pass Fail Date Tested:LL
(Failed test requires owner's 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 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)
Owner's Signature Date