HomeMy WebLinkAbout1531 W Swallow Rd - Special Inspections/Field Verification - 03/18/201203-19-12;08:30AM;
3/ 3
City of
Fort Collins
Combustion
Replacement of Nat
Address: S3I G%
Approved Agency:
Technician Name (p a
Technician Signs e.e
Appliance Teste
Appliance Repla _
Worst Case Conditions:
lw
Planning, Development & Transportation Services
Community Development & Neighborhood Services .
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.OS80
970.416.2740
970.224.6134- fax
fcwv.com
Test Comp 'ance Form
F
aft Appliane in Existing Houses 1
2 G Permit Number: ` 2'� ` 2--
Jc�
t1 Company �il✓-. c 4�/�.0�� ���� ,�
Date 3�/�-/i:_
Spillage Duration (in seco s): Carbon Monoxide (parts per million):
Pass Fail Date Tested: -7— /* %L
(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 -ease conditions. I acknowledge that
I have received a combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature Date