HomeMy WebLinkAbout705 Birky Pl - Special Inspections/Combustion Safety - 03/08/2016i
Planning, Development & Transportation Services
City Of
®rt Collins
Replacement
Address: ;,P& g Y, % ��>,
Approved Agency: f
Technician Name (print):
Technician Signature:
Appliance Tested: �✓ 1
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in sec nds):
Pass F
(Failed test
Natural Conditions:
Spillage Duration (in seconds):
Pass F
Commurlty Development & Neighborhood Services
281 North College Avenue
P.O. Sox 580
Fort Collins, CO 80522.0580
976.416.2740
970.224.6134-fax
fcgov.com
Ion Safety Test Compliance Form
Natural Draft Appliances in Existing Houses
Permit Number: Q) 6 01 A 0 V
Company A, Z Le r, c C—'
Date 3 — ? Jl
Carbon Monoxide arts :
per million
(p p )
Date Tested:
owner's signature acknoWedging results.)
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes cinder Natural Conditions.)
Technician's recommendations (o correct tested appliance failure: '
I certify that I am the legal own r 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 liance safety information sheet.
Owner's Name (print)
Owner's Signature
Date