HomeMy WebLinkAbout2132 Andrews St - Special Inspections/Combustion Safety - 05/14/2015City ®f Community Development
Fort Collins281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address:,
i 1 J2 AMO U V s Pen -nit #:
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print):
Technician Signature:
Appliance Tested:
Appliance Replaced:
(1
��S-FUYV I �l {'I Gill �1� iliq
Date ��1'i/i'_-no �J
Worst Case Conditions:
Spillage Duration (in sec ds): _ Carbon Monoxide (parts per million):
Pass 7 Fail Date Tested: r Z ( LA j
Natural Conditions:
Spillage Duration (in sec nds): Carbon Monoxide (parts per million): �r6
Pass Fail Date Tested: A LA f
(Failed test requires corrections until test passes under 16tural Conditions)
Technician's
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:replacement/natural-draft/4.25.12
Date
aHlE4�