HomeMy WebLinkAbout1709 Falcon Ridge Dr - Special Inspections/Combustion Safety - 10/21/2014F6rt
Cit ®f Community Development
Collins 281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: /7c�; <z�or ��e- Ir- Permit #: -R / ell 'o 3��
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, Februa-r-y-2012.
Technician Name (print): oJe s �- 1 ��„ Com any A7z Y/, �,., 1 457
Technician Signatures" ///_'' / Date
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): 3 p Carbon Monoxide 7(pas per million): f J
Pass Fail Date Tested: o
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (part per million):
Pass Fail Date Tested: r� o/
I ,
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct�ested appliance failure:
AI. / } I % - .I,
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