HomeMy WebLinkAbout3002 W Elizabeth St - Special Inspections/Combustion Safety - 11/30/2015 (2)I
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Fort Collins
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Replacement
Address: 300 Z E
Approved Agency:
Technician Name (print):
Technician Signature: _
Appliance Tested: �✓,w��
Appliance Replaced:,,, z
Worst Case Conditions:
Spillage Duration (in seconds)
Pass _ e- 1
(Failed test re
Natural Conditions:
Planning, Development & Transportation Services
Community Development $ Neighborhood Services
281 North College Avenue
P.O. •Box 580
Fort Collins, CO 80522.0580
976.416.2740
970.224.6134-fax
fcgov.com
Safety Test Compliance Form
iral Draft Appliances in Existing Houses
Permit Number: O-Af4- 7793
Company 41ltn
Date //- 3o - Is -
D Carbon Monoxide (parts per million)
Date Tested:
owner's signature acknowledging results.)
Spillage Duration (in seconds): -1 Carbon Monoxide (parts per million):
Pass Fa�l Date Tested:
(P,ailed test requires c} rrections until test passes under Natural Conditions)
Technician's recommendations io correct tested appliance failure:
I certify that I am the legal own r 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 ap liance safety information sheet.
Owner's Name (print)
Owner's Signature - Date a.3 o I ?n l5