HomeMy WebLinkAbout812 Grandlake Ct - Special Inspections/Combustion Safety - 11/11/2014Planning, Development & Transportation Services
CitOI Community Development & Neighborhood Services
y Cp 261 North Cottage Avenue
P.O. Boxt Collins Fort Co6ins
60
¢ of , CO 80522.0580
970AI62740
970.224.6134- fax
kgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft la�tApppliances in Existing Houses
J ,
Address: AF/ 2 (Llt( r\4 �Ol t�+C (� Permit Number: 2f
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 Foil Collins Combustion Safety Test Guide
Version 5, February 2012.
Technician Name (print): Zo 109ef-- Company WC
Technician Signature: "� — Date
Appliance Tested:
Appliance Replaced: 71�j{y
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts perlIlion):
Pass Fail Date Tested: —T
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test requires corrections until rest passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I certify that 1 am the legal owner of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst -ease conditions. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST: reel acement/natural • d raft/4.25.12
Date