HomeMy WebLinkAbout2960 W Stuart St - Special Inspections/Combustion Safety - 03/04/2016Community Development
F 281 N. College Ave.
ort Collins PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134(fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: �� s j(G� Permit #: 13:1,6 0..1-.=;:a•: .
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print): Company �;�'15/e
Technician Signature: Date
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass X Fail
Date Tested:
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires 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
C ST:repl acement/natural-draft/4.25.12
Date