HomeMy WebLinkAbout3909 Ridgeway Ct - Special Inspections/Combustion Safety - 02/26/2015Planning, Development & Transportation Services
City OI Community Development S Neighborhood Services
281 North College Avenue
F/ rt Collins P.O. Box580
��-,��J'�" ` Fort Collins, CO 80522.0560
970.416.2740
970.224.0134-fax
kgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: Loma y C Permit Number: CL5
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
Technician Name (print):
Technician Signature: _
Appliance Tested:
Appliance Replaced: _ ±tV L
Version 5, February 2012.
Company /v (A
Date _Z
Worst Case Conditions: /
Spillage Duration (in seconds): b w Carbon Monoxide (parts per million):
Pass Fail Date Tested: — 2 6 ( S
Natural Conditions:
Spillage Duration (in seconds): _ 60 Carbon Monoxide (parts per million):
Pass �k Fail Date Tested: ? ` Z 6 — ( 5
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to convect 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:replacemendnatural-draft/4.25.12 C^
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