HomeMy WebLinkAbout1742 Eastwood Ct - Special Inspections/Combustion Safety - 04/17/2015Planning, Development & Transportation Services
Community Development S Neighborhood Services
CR & 281 Florin College Avenue
P.O. BOX 680
efcothn-S Fort Collins, CO 90522.0580
rY� 970.416.2740
970.224.6134- fax /
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appiiancm in Existing Houses
Address: i % yz Permit Number. /3 / 56 Z O to
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 (print}: ,'c C W Company 061-14) e . << 17 Lvm t ,`.I c,
Technician Signature' .,Date
1
Appliance Tested: W 0-4r r Yi ele r
Appliance Replaced: W a yir
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fait Date Tested: 4/ i 7 / zv / 5r
Natural Con ' ions:
Spillage Duration (in seconds): — I Carbon Monoxide (parts per million): r3
Pass 7k, .. Fail Date Tested: V/ 7 zv sJ
(Failed test requires correcdons undid testplawes wilderNaturad Cenditions:)
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:replacamendnatatal-draIV4.25.12
Date -T za15J