HomeMy WebLinkAbout1335 Red Oak Ct - Special Inspections/Combustion Safety - 07/05/2017Fcltryf��C
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: /�� = Gl y'�' Permit #:
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Te#t Guide Version 5, February 2012.
Technician Name (print):
Technician Signature.
Appliance Tested:
Appliance Replaced:
Company
Date
Worst Case Conditions: _
Spillage Duration (in secon ): 5 Carbon Monoxide arts er million):
Pass Fail Date Tested: `7 _
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