HomeMy WebLinkAbout1550 Blue Spruce Dr - Special Inspections/Field Verification - 06/14/2012Jun 14 12 03:33p Hahn Plumbing
9704935325 p.1
Planning, Development & Transportation Services
City 0 91 North urdtY
evee opment a Nerghborhood Services
Fort Collins Fort Coffins, s,CO80522.0580
970.416.2740
970.224.6134- fax
kgovcom
Combustion Safety Test Compliance Form
ReNaturalcemeent of Natural Draft Appliances in Existing Houses
Address: Ko JP �w r Permit Ntunber: J 1 L D) O 1 q
Approved Agency:
Technician Name (print):
Technician Signature: Date L-l'l-%rZ .
Appliance Tested:
Appliance Replaced: 4-20
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass P Fail Date Tested: � -I+ I -
(Failed test requires owner's signature acknowledging results)
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass P�" Fail Date Tested: 0-1U •tL
(Failed iest 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