HomeMy WebLinkAbout2012 Bronson St - Special Inspections/Field Verification - 06/01/2012Planning, Development & Transportation Services
Huy
Community Development & Neighborhood Services
?k y c = 281 North College Avenue
h P.O. Box 580
�'+so � Fort Collins, CO 80522.0580
' 970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: ZO/Z-4 .AlSdAI Permit Number. �Zo318eg
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012.
Technician Name (print): �:�',ku), I ,fit 5J,-,v Company / ,,'OEM —t> %,
Technician Signature: /2.:..(A �� Date c-cN6--
Appliance Tested: C,(I fi j i
Appliance Replaced: J A),
Worst Case Conditions:
Spillage Duration (in nds): 0 Carbon Monoxide (parts per million):
Pass Fail Date Tested:,uu_2 1 `EcDf Z
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass X Fail Date Teste&-- itsL I , 79 I `y
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
ed 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 conditiom. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print) T i N 1�•�� 5
Owner's Signature
CST:replacemendnatumi-dmft/4.25.12
Date.TGt Aas C- / , -t> l Z