HomeMy WebLinkAbout4136 Sumter Sq - Special Inspections/Combustion Safety - 06/12/2014Planning, Development & Transportation Services
City of
.Fort. Collins
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
870.224.8134- fax
kgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: �#3 6 , rlyl lB ' S Q OAOC Permit Number:
%3 I `-I 0.31- �-
Approved Agency: ///I Pd-
Technician Name (print): Company /�Date
te
Technician Signature: = D
Appliance Tested:
Appliance Replact
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass _Ig_ Fail Date Tested: ( — / 2 —
(Failed test requires owner's signature acknowledging results.)
Natural. Conditions: lJ
Spillage Duration (in seconds): 2SJ Carbon Monoxide (parts per million):
Pass `tZ Fail Date Tested: o —/ 2 Iy
(Failed test requires corrections until test passes under Natural Condition&)
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