HomeMy WebLinkAbout6709 Antigua - Special Inspections/Combustion Safety - 07/17/2014FROM :NCA FAX NO. :9702299983 Aug. 20 2014 10:01AM P3i3
Planning, Development & Transportation Services
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Fart Collins P.O.BOX�
Fort ColX 5 00 ti0522.0590
970A19.2710
970.2244194- W
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses $14,Zq oq
Address: �70 2 Aq Cf0( Permit Number: Iqq0N*
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have perfnnned the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version S, February 2012.
Technician Name (print):
Technician Signature: _
Appliance Tested:
Appliance Rcplawd:
Worst Case Conditions:
Spillage Duration (in seconds):
Company—L—C''. r.. _
Date
3 ® Carbon Monoxide (parts per million): D_
Pass __'IN Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): 30 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:
Failed Worst Case Conditions:
I certify that i am the legal owner of the above listed property and hereby acknowledge that my appliance
has tailed a Combustion Safety Test under worst -case conditions. I acknowledge that 1 have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST: replacement/natural-draft/4.25.12
Date