HomeMy WebLinkAbout718 Powderhorn Dr - Special Inspections/Combustion Safety - 12/17/2014Planning, Development & Transportation Services
Clay, or a Community Development 8, Neighborhood Services
®�� /�®<���lS P.O.o281 hCollegeAvenue
P.O. Box 580
Fort Collins, CO 80522 0580
970.416.2740
970.224.6134-fax
/cgov.corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses]
Address: _71 Ki 90 Q;r-I-,orh Permit Number:
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.
Technician Name (print): 'S (Ir,"SA, Company P,C
Technician Signature: _141 r Date % 7 PI
Appliance Tested:
Appliance Replaced: �/z H
Worst Case Conditions: //
Spillage Duration (in seconds): Del Carbon Monoxide (parts per million): c�
Pass ,� Fail Date Tested:
Natural Conditions: /
Spillage Duration (in seconds): t; it Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test requires corrections until test 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 -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