HomeMy WebLinkAbout2110 Brookwood Dr - Special Inspections/Combustion Safety - 10/20/2015Planning, Development & Transportation Services
ym. ;sn _X Community Development & Neighborhood Services
�:_;:�. dr 0 a 281 North College Avenue
�P.O. Box 580
®rt Collins Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov. com
Combustion Safety .Test Compliance Form
Replacement
of Natural Draft Appliances in Existing Houses
Address: 9 //O �-7/ZOO/CGUUO,� � �, Permit Number: �5
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Sai ty Test in accordance wj& Fort Collins Combustion Safety Test Guide
Version , February 2012.
Technician Name (print):Company
Technician Signature: — Date
Appliance Tested:'
Appliance Replaced:F Gt�w f�r�2
Worst Case Conditions:
Spillage Duration (in seconds): Q Carbon Monoxide (parts per million):
Pass ✓ Fail Date Tested:
Natural Conditions: O
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass ✓ Fail Date Tested: ®
(Failed testrequires corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
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
CST:replacement/natural-draft/4.25.12
Date