HomeMy WebLinkAbout743 Blue Mountain Dr - Special Inspections/Combustion Safety - 01/23/2014I
CitytCollins
of
Community Development
281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement toff Natural Draft Appliances in Existing Houses
Address: /7 ?j Permit#: ►,J 1370 �/�✓
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety fest Guide Version 5, February 2012.
Technician Name (print):' //We64Yjj)WCompany
Technician Signature: I Date / - 2
Appliance Tested: / wo,_;O�
Appliance Replaced: I�I vI ga r -e
Worst Case Conditions:
Spillage Duration (in seconds): �� Carbon Monoxide (parts permillion):
Pass Fail Date Tested: 1-2-3-It/
.ti
Natural Conditions: �X
Spillage Duration (in seconds). Carbon Monoxide (parts per million):
Pass Pass V% Fail Date Tested: 1-2—*3
(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
Date
CST:replacement/natural-draft/4.25.12 1.
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