HomeMy WebLinkAbout1550 Blue Spruce Dr - Special Inspections/Combustion Safety - 08/14/2015planning, Development & Transportation Services
community Development & Neighborhood Services
Clty, of 281 North College Avenue
Fort Collins P.O. Box 580
Fort Collins. CO 805220580
970.2740
970.224224.613d-fax
rcgov.wm
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
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Address: h �� t 3 t - 'er a � 2 t r Permit Number:� lSG (, I01
Approved Agency:
Technician Name (print):
Technician Signature:
Appliance Tested: `�l ` a
Appliance Replaced: 70
Worst Case Conditions:
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Company
Date
Spillage Duration (in seconds): Z Carbon Mono-)dde (parts per million):
Pass k Fail Date Tested: S' (.4-/S-
(Failed test requires owner's signature aelinowledgifrg results.)
Natural Conditions:
Spillage Duration.Un seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
Lf
(Failed test requires corrections until test passes tinder Natural Conditions.)
Technician's recommendations to 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 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
Date
Z-d 9Z£9-£6b-0L6 Buiqwnld ugeH eZO:OI 9l LZ 100