HomeMy WebLinkAbout2001 Canopy Ct - Special Inspections/Combustion Safety - 07/13/2015Planning, Development & Transportation Services
Commurlty ®eveiopment 8, Neighborhood Services
l� y� f 281 North College Avenue
For
Collins I P.O.3ox 580
� Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
Icgov.com
I
Combos flon Safety ']hest Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
i
Address: 20o 1 CAS otp Gf Permit Number:
Approved Agency:
Technician Name (print): .4 AiLL Company d4LLC4.) 7)avr_C
Technician Signature: �'�-�-- - Bate 7/45
Appliance Tested: 0A
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass iC Fa l Date Tested: 7/1.3 //g
(Failed tese regtires oivner'.s signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds)
Pass 1
(Failed test reelaurres
Technician's recommendations
Carbon Monoxide (parts per million):
:Date Tested:
r'L'crians giVil test passes under Natural Condidonti.)
correct .tested appliance failure:
I certify that I am the legal owngr of the above listed property and hereby acknowledge that my
appliance has failed a Combustihn Safetv Test tinder word` -case eonditeons. T acknowledge that
I have received a combustion appliance safety information sheet.
Owner's Name (printl
Owner's Signature Date