HomeMy WebLinkAbout5220 Boardwalk Dr - Special Inspections/Combustion Safety - 04/29/2016Ea;topZMZ613' 11:37:05a.m. 09-28-2012 1 /1
Community Development
281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 &X)
fcgov corrrldevatopment
Combustion Safety Test cCompHaace IFor, M
Replacement of Natival Draft .AppRances; in Existiaag Douses
Address: ��a ��A,��I�G.� �' . /7iPermit#:
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): i /1'� � Company z, k-!%� ,�,4,.,�,�.(
Technician Signature:/"�lw �1�� Date
Appliance Tested: W-A`
Appliance Replaced: Wa4e-rLe� .
Worst Case tCondifloins:
Spillage Duration (m seconds): _ Carbon Monoxide (parts per million): /'C.>
Pass Fail Date Tested-
Natural cCo><ndition=
Spillage Duration (in seconds): Carbon Monoxide (parts per million): °
Pass Pail Date Tested,.
(Mauled test rregaar'lres correcftaas angel rest passes tagader NaAuirat iCondidenr)
Technician's recommendations to correct tested appliance failure:
Meal Wo rat Case cCO>mMICImso
I certify that 1 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 aclmowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST:replacement/natural-dmN4.25.12
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