HomeMy WebLinkAbout330 W Laurel St - Special Inspections/Combustion Safety - 10/12/2016Community Development
�,� I 281 N. College Ave.
F®rt Collins PO Box 580
,1�� Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: _�3(2 L J, be ,? d— P-3 Permit #:
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): t Company ,,,L, ��r� &XVt &!-f- i, l--gyp
Technician Signature: Date to
Appliance Tested:�� - £-
Appliance Replaced: tom.%.
Worst Case Conditions:
Spillage Duration (in seconds): LI ) Carbon Monoxide (parts per million): I C,
Pass_ Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): (o L Carbon Monoxide (parts per million):
91
Pass _ Fail Date Tested: t O '2--j
(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