HomeMy WebLinkAbout1642 Fantail Ct - Special Inspections/Combustion Safety - 12/05/2014 (2)Planning, Development & Transportation Services
Community Development & Neighborhood services
City of
L, �� ��2al North
���� College Avenue
• P.O. Box 580
Fort Collins, CO 80522 0550
i L 970A1t1.2740
970.224.6134-fax
fcgov. wm
Combustion Safety Vest Compliance Form
// Replacement of Natural Draft Appliances in Existing Houses �f
Address: q:2 Permit Number: LI ✓4
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):
Technician Signature:
Appliance Tested: _
Appliance Replaced: T HkC4
Company O)c1*
Date 12 /5-
Worst Case Conditions: '{
Spillage Duration (in seconds): 31 Carbon Monoxide (parts per million):
Pass i/ Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's 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
CST:replacement: natural-draft.'4.25.12
Date