HomeMy WebLinkAbout4930 Smallwood Ct - Special Inspections/Combustion Safety - 06/30/2016�f Community Development
������ l �� 281 N. College Ave.
F6rt
Collins 7pm
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
kgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing houses
Address: -- �1 <,Z�xrr, op., x Permit #: i btu �J-1
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` o �Y
Technician Signature: Dateg�} 11ss
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): I— Carbon Monoxide (parts per million):
. Pass � Fail Date Tested: �
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
I certify that I am the ieg�ai-9 J'ef-et`ttlt`atsove-listed-Prn and hereby acknowledge that my appliance
has failed aiCetn i Safety Test under worst -case conditions. Aura owledgeshat.-I Kaye received a
appliance safety information sheet.
Owner's Name (print)
6
Owner's Signature _� �7 -( N-y c� Date
CST:replacement/natural-draft/4.25.12