HomeMy WebLinkAbout531 Saturn Dr - Special Inspections/Field Verification - 04/21/2012Planning, Development & Transportation Services
City ®f community Development & Neighborhood Services
F6rt
Y281 North College Avenue
P.O. Box 580
Collins Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft%A%ppuances in Existing Houses
Address:
lrF!►/ ��� h �•� hS Permit Number:
Approved Agency:
Technician Name (print): f%YYl,�fc_ Company
Technician Signature: Date
Appliance Tested:
Appliance Replaced: fn j
Worst Case Conditions:
Spillage Duration (in s%nds):. Carbon Monoxide (parts per million):
Pass i/ Fail Date Tested:
(Failed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duratio Q (in-sec/eFail nds): Carbon Monoxide (parts per million):
Pass
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
n
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