HomeMy WebLinkAbout1112 W Oak St - Special Inspections/Combustion Safety - 11/21/2014 (2)fort Collins
Planning, Development & Transportation Services
Community Development d Neighborhood SerAm
281 North College Avenue
P.O. Box 680
Fort Collins, CO B0522.0580
970A16.2740
970.224.6134- fax
rcyovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: I I 2 1n% DiNk ,- Permit Number: 22 4
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. I Technician Name (print): CUl C. a f kr Company I(/C6
Technician Signature: Date f 1-11 �1
Appliance Tested: UaAr- Ilea
Appliance Replaced: �f_tnta GP
Worst Case Conditions:
6
Spillage Duration (in seconds):
Carbon Monoxide (parts per million):
Pass Fail
Date Tested: I -21 —/ %
Natural Conditions:
60
Spillage Duration (in seconds):
Carbon Monoxide (parts per million):
Pass Fail
Date Tested: 11-11 1 y
(Failed test requires corrections trtttil test passes trader 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:rep lacement/natur-al-dralt/4.25.12
Date