HomeMy WebLinkAbout5529 S Timberline Rd - Special Inspections/Combustion Safety - 11/24/2015.R.-Y Of
Fort Collins
Combi
Replacement
Address: `
Approved Agency:
Technician Name (print)
Technician Signature:
Appliance Tested:
Appliance. Replaced: LA-J-4-
Worst Case Conditions:
Spillage Duration (in seconds):
Pass l F
(Failed test
Natural; Conditions:
Spillage Duration (in secon ):
Pass F
(Failed test requires c
I
Techniciaili's recommendations
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. 3ox 580
Fort Collins, CO 80522.0580
976.416.2740
970.224.6134-fax
Icgov.com
ion Safety Test Compliance Form
Natural Draft Appliances in Existing Houses
Permit Number:
M -04 n.—z-- Company sal It
\,4-, _R rate
. Carbon Monoxide (parts per million):
Date Tested: t l -Zcf- 1
owner'.v signature acknowledging resultv.)
Carbon Monoxide (parts per million):
Date Tested:
until test passes under Natural Conditions.)
correct tested appliance failure:
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 ap plidnce safety information, sheet.
Owner's Name (print)
Owner's Signature
Date