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HomeMy WebLinkAbout1701 Brentford Ln - Special Inspections/Combustion Safety - 09/28/2015 (2)1 t:.71:U.7a.M. w—to—ay.a Katy©t For C0-- � DP- Cambilatiop- Safety Test lm,eplaeement of Nadal Draft Ap Address: 1-70 t 9 -bA ICI Approved AFMCY: g hereby attest that I have performed the following Con Fort CoMw Combustion Safety Test wide Technician Name (print): ft t— "L NVLMLL Technician Signature: - Appliance Tested `Z Appliance replaced:. Worst Case c auffi loans: - 5pillage :Durataon Cm seconds): 00 Carbon Vonc pass call Dai:-e Tested-. Cemmunity Development 261 N. CallegeAve. PO Box 590 Fort Collln% CO SOM 970,416.2740 910.22A.5i34 (Fes) ft�ovapm/developmenr Mee Forrlm 1R Fanstifus Boluses 1�T�>i�r�srIl �®mc�ifiomso Spillage Dint ion (in seconds)*. Carbon Monw ?ass X- hail Date -restaa10 _ Permit #: 9 / ! O 795 m Safety Toss in accordance with On 5, Febreaw 2012. My �l Date c.T — z,Y—/ S (parts permcan}:y — Z- —(.- (pasts per million)• l /zY ''irNalaral Cogad ow) Technician's recommendations to correct tested appliance fglure: ....... F& I vd Worst Case (Coro diflomiso I cer* -fat i am the legal wamer of the above listed property and lareby adknowledge that my appliance has famed a Combustion Safety Test under Worst -case eQaaM039 i a+clmowledge that i have received a combustion appliance sdety information sheet. Ownoes Name (print:) Owner's Signature C5'i'WbcementfMtuml-dEaftl IM.12 Date Zs-