HomeMy WebLinkAbout7221 Fort Morgan Dr - Special Inspections/Combustion Safety - 08/28/2015Planning, ;velopment & Transportation Services
community Development & Neighborhood Services
City of 281 North College Avenue
P.O.3lxli
,rv�,®rt Collins . Fort Collins, CO 80522.0580
/ I 970.416.2740
970.224.6134-fax
fcgov. corn
III
Combu4ion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
i
i
Address: �2 2 o l t' y�l vt O r Permit Number:,(
Approved Agency: f
Technician Name (print): �� {�(A Company )e l cep
Technician Signature: zo�Date
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass 1�_F
(Failed test
Natural Conditions:
Spillage Duration (in seconds):
Pass // - F
(Failed test requires
Technician's recommendations
2 Carbon Monoxide (parts per million):
Date Tested: 8�, L<-
owrter'.s signature acknowledging results.)
Carbon Monoxide ((parts per million):
Date Tested:
until test passes under Natural Conditions.)
correct tested appliance failure:
I certify that I am the legal ownir 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 9• Z sf • /.s