HomeMy WebLinkAbout5224 Abbey Rd - Special Inspections/Combustion Safety - 11/24/2014City of
Fort Collins
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, Co 80522.0580 (/ /G��
970.416.2740 `] / / / ' /
970.224.6134- fax
(cgov.com
Combustion Safety Test Compliance Form
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Replacement of Natural Draft Appliances in Existing Houses
Address: 62A AMy zl�> Permit Number:
/• /7-- /s
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. n
Technician Name (print): &Z� Tk OLA� C_ ompany
Technician Signature: - Date
Appliance Tested: L,77— mil, l•�`-VU— Wffe .,
Appliance Replaced- JE�—'T WPs`c
Worst Case Conditions:
Spillage Duration (in second ): _ Carbon Monoxide (parts per million): %�
Pass Fail Date Tested: 1-2 —1
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.)
recommendations to correct tested appliance failure:
Failed 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 conditions. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature Date
CST:replacement/natural-draft/4.25.12