HomeMy WebLinkAbout2215 Dolan St - Special Inspections/Combustion Safety - 09/25/2015City of
Fort Collins
Community Development
281 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: zz SJ b/G-✓t, '9i Permit #: j
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: �y�t,& kzik�
Appliance Replaced:yhtz'
Worst Case Conditions:
Spillage Duration (in seco as): _
Fail
Natural Natural Conditions:
Spillage Duration (in sec o ds): _
Pass Fail
/
Company % l'40
Date 2
Carbon Monoxide parts per million):
Date Tested: 7 - ZS LC
Carbon Monoxide (parts per million):
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 I am the legal owner of the above listed properly and hereby acknowledge that niy 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: rep I acement/natural-d rat t/4.25.12
Date