HomeMy WebLinkAbout2059 Stoney Hill Ct - Special Inspections/Field Verification - 04/24/2012Planning, Development & Transportation Services
Fort Collins
CornntufY Developmeot & Wk;hborhoW services
281 Worth College Avenue
P.O. Box 580
Fort CoWins, CO 80522.0580
970.416.2740
970.224.6134- tax
kgov.corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address 267 S� /Act/�f- /,' // " Permit Number: /3 / Z7 0/
Approved Agency:
Technician Name I
Technician Signati
Appliance Tested:
Appliance Replace
Worst Case Conditions:
Itc>
Spillage Duration (in seconds): e �0 Carbon Monoxide (parts per lion): �� �/ '—
Pass Fail Date Tested:/-�%��Z
(Failed test requires owner's signature acknowledging 'results)
Natural Conditions:
Spillage Duration (ins nds):. 10516, Carbon Monoxide (parts per million): 3�
Pass Fail Date Tested:/e�Pi4
(Failed test requires corrections until test passes under Natural Conditions)
T hnician's recommendations to correct t1�ed appliance failure:
�T
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 (prmt-/;�e�NaZ� 49076
Owner's
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