HomeMy WebLinkAbout2301 Mathews St - Special Inspections/Combustion Safety - 05/12/20151UN/03/2015/WED 11:49 AM FAX No, P,016
Planning, Development & Transportation Services
i k Community bevelopment & Neighborhood Services
A of 281 North college Avenue
Fort Cotli ns Fort Box 590
�• Fart Collins, CO 80522.0580
416,2740
970.224.6134- fax
fcgov.mm
C"a
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 7 Q 1 YAA S �T Permit Number: � Q 3l1 l
Approved Agency:
1 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. II
Tecbnician Name (pru}t Company(I OCC.d0 d4a ftlCe-6AV ical
Technician $!mature: '�.. Date l2 S
Appliance Vested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): _
Pass V Fail
- Carbon Monoxide (parts per million):
Date Tested: 6h i' 6
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass J Fail Date Tested: 2
(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 I arm the legal owner of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst -case conditions. 1 acknowledge that I have received a
combustion appliance safety information sheet.
Ownm`.4 Name (print)
Owner's Signature _
CST:replacennenldnatutal-draft/4.25.12
Date