HomeMy WebLinkAbout800 Foxtail St - Special Inspections/Combustion Safety - 09/22/2014City of
Fort Collins
Replacement
Address: Z;VU tz Ok
Approved Agency:
Technician Name (print):
Technician Signature: .,!�
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds)
Pass 4 1
(Failed test
Natural Conditions:
Spillage Duration (in seconds):
Pass I'C F
(Failed test requires
Technician's recommendations
Planning, Development & Transportation Services
Community Development S Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
lcgov.com
lion Safety Test Compliance Form
'Natural Draft Appliances in Existing Houses
Permit Number: 13Iq D � 3
Company a,GLe,� 5era¢v
Date of -ZZ -/ q
Carbon Monoxide (parts per million): `o
Date Tested: 9,Z Z- / (
owner's signature acknowledging results.)
Carbon Monoxide (parts per million): (/
Date Tested:
until teat passes under Natural Conditions.)
correct tested appliance failure:
I certify that I am the legal own r 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 ap liance safety information sheet.
Owner's Name (print)
Owner's Signature Date