HomeMy WebLinkAbout5620 Fossil Creek Pkwy - Special Inspections/Combustion Safety - 04/07/2015APR/20/2015/MON 11:50 AM DELTA MECHANICAL -AZ FAX No,480-898-0005
P. 004
Planning, Development & Transportation Services
City, ® Community Development & Neighborhood Services
281 North College Avenue
F6 ` Collins P.O.Bax580
Fort Collins, CO 80522,0580
970A16.2740
V ' 970.224.5134- fax
✓'� fcgovcom
Combustion Safety Test Compliance Form
NReplacement of Natural Draft Applinuces in Existing Rouses
Address: G2� ���� CCeG� >PPermitNumber:15ZSII
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 (p ✓ Company (16101rejo W46, 1 t t6anidal
Technician Signature: Date41-7116
Appliance Tested: k i
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): . Carbon Monoxide (parts per million):
Pass V/ Fail Date Tested: ' 1
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass V Fail Date Tested: C
(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:replacementlnatural-drafr/4.25.12
Date