HomeMy WebLinkAbout1120 Lakecrest Ct - Special Inspections/Combustion Safety - 11/04/2014_Water neateri tallf6f.46taffil
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City ®f
Fort Collins
Combs
Replacement
Address: //), 0
Approved Agency:
Technician Name (print):
Technician Signature:
Appliance Tested:
Appliance Replaced: V1
Worst Case Conditions:
Spillage Duration (in seconds):
Pass-4 F
(Failed test ret,
Natural Conditions:
Spillage Duration (in seconds):
Pass F
Planning, Development & Transportation Services
Community Development S Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
tcgov.com
:ion Safety Test Compliance Form
Natural Draft Appliances in Existing Houses
jT ( --r
Permit Number:
Company �IG(�P �.� rr✓'') C
Date
zZ Carbon Monoxide (parts per million):
1 Date Tested:
Tres owner's signature acknowledging results.)
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations tiro correct tested appliance failure:
I certify that I am the legal own r of the above listed property and hereby acknowledge that my
appliance has failed a Combusti n Safety Test under worst -case conditions. I acknowledge that
I have received a combustion aptliance safety information sheet.
Owner's Name (print)
, Owner's Signature _
Date //*f j f