HomeMy WebLinkAbout5115 Southern Cross Ln - Special Inspections/Combustion Safety - 04/27/2016C®dins
Planning, Development &'transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580:r 4.
970.416.2740 3 `'
970.224.6134- fax b
fcgov.com MAY 0 5 2016
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: <i! � 50�. (ra55 t^ Permit Number:
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012.
j�
Technician Name (print): '17V. A. r.41 Company �lps
Technician Signature: `� Date
Appliance Tested:
Appliance Replaced: Za A.
Worst Case Conditions:
Spillage Duration (in seconds): Z
Pass K Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
. Carbon Monoxide (parts per million):
Date Tested: Ly-Z-7 _It,
Carbon Monoxide (parts per million):
Date Tested:
�7
(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 informationsheet.
Owner's Name (print)
Owner's Signature
CST: rep l ac em ent/n atural-draft/4.25.12
Date