HomeMy WebLinkAbout3301 Kittery Ct - Special Inspections/Combustion Safety - 02/24/2015Planning, Development & Transportation Services
CityCI}�i OF Community Development& Neighborhood Services
, 281 North College Avenue
P.Box 50
Fort Collins Fortrt Colli s8 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:—?-? G ( �{-Q r V CT Permit Number: 5�0 I
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
1 r Version'S, February 2012.
Technician Name (print):
Technician Signature:_
Appliance Tested:
Appliance Replaced:
Company
Date Z — -Z,
Worst Case Conditions:
Spillage Duration (in seconds): Q Carbon Monoxide (parts per million):
Pass �_ 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 Lam 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 1 have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature _
CST: rep lacement/natural-draft/4.25.12
Date