HomeMy WebLinkAbout3939 Rannoch St - Special Inspections/Combustion Safety - 08/07/2013y
City o4 F�
Fort Collins
Planning, Development rti Transportation Services
Community Development 3 Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- tax
2gov.com
Combustion Safety.Test Compliance Form
2 q Replacement o Naturall Draft Appliances in Existing Houses
Address: 3 I 1 IC G1 AY1 o C, Permit Number: ]3 ) 30 ggjj 7/O
Approved Agency: _
Technician Name (print): e v U /1 � r Company n- /�t N n se rU/ Cp e
Technician Signature: Date ?2- L 1J
Appliance Tested: S li A heakr
Appliance Replaced: So Ci Wq, r keA.
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide(partsper million): J
Pass J�/__ Fa�-Date Tested:
(Failed test req�ires owner '.s signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds): �_ Carbon Monoxide (parts per million):
3
Pass O"' Fa Date Tested: �- 7'
(Failed test requires• c rrections until test passes carder Natural Conditions.)
Technician's recommendations io correct tesScd appliance'failure:
i
I
I certify that I am the legal ON
appliance has failed a Combu
I have received a combustion
Owner's Name (print)
of the above listed property and hereby acknoWfedge that my
i Safety Test under worst -case conditions.. I acknowledge that
safety information sheet.
Owner's Signature I Date