HomeMy WebLinkAbout721 Parkview Dr - Special Inspections/Combustion Safety - 06/15/2016Planning, Development & Transportation Services
� Community Development & Neighborhood Services
F
I � �' t 281 North College Avenue
Fort Collins Fort Colli s$ CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 72/ 10,81? Z 21r% ,D/Z Permit Number: 0 1 6 U? 3 Y I
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.
Technician Name (print): 04 67— Company
Technician Signature: Date
Appliance Tested:
Appliance Replaced: �414f: ?7�
Worst Case Conditions:
Spillage Duration (in seconds):. Carbon Monoxide (parts perillion):
Pass !/ Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
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
CST: replacement/natural-draft/4.25.12
Date