HomeMy WebLinkAbout2119 Langshire Dr - Special Inspections/Combustion Safety - 08/04/2015Plannk, ent & Transportation Services
City Of
Fort Collins
Con Yelopmont & Neighborhood Services
281 Noi, .lege Avenue
P.O. Sox , l 1
Fort Collins, CO 80522.0580 �I 1/1 alC/J 1 s
9711.416.2740
370.224.6134-fax � V
lcgov.com
Combusition Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Douses
Address: i3 // 7 /.,,
Approved Agency:
Technician Name (print):
Technician Signature: _
Appliance Tested: —,1
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass
(Failed test
Natural Conditions:
Spillage Duration (in seconds):
Pass —L-�-<r
(Failed test requires
Technician's recommendations
Permit Number: L
Company ,A
Date
. Carbon Monoxide (parts per million):
Date Tested:
owner's signature acknowledging results.)
Carbon Monoxide (parts per million):
Date Tested: C���o,L�x✓S�
until test passes under Natural Conditions.)
correct tested appliance failure:
I certify that I am the legal owner of the above listed property and hereby acknowledge that my
appliance has failed a Combustibn 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 Date