HomeMy WebLinkAbout2226 W Elizabeth St - Special Inspections/Combustion Safety - 08/01/2017FCity
t` Collins
of
Community Development
281 N. College Ave.
PO Box 580
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: �% w r, � Permit #: J Z r/
Approved Agency:
1 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): C/vl,�/1 Company
Technician Signature: 4, Date 9--/ — I%
Appliance Tested: 1 5 1) GY'97 ' -
Appliance Replaced: 5 �..�.
Worst Case Conditions: z
Spillage Duration (in secon s): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
Natural Conditi s:
Spillage Duration (in sec nds): Carbon Monoxide (parts per million):
Pass Fail Date Tested: ' (-
(Failed test requires corrections until tesLtp=ys under Natural Conditions)
Technician's recommendations t rect tested appliance failure:
Failed W,pfst Case Conditions:
I certify thITI am the legal owner of the above listed pro and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst- conditions. I acknowledge that I have received a
combustion appliance safety information she
Owner's Name (print)
Owner's Signature
IL
Date