HomeMy WebLinkAbout1245 Lincoln Ave - Special Inspections/Combustion Safety - 05/01/2017= I
Community Development
281 N. College Ave.
o Box 580
F
Fort Collins, CO 80522
.>� 970.416.2740
970.224.6134(fax)
1A fcgov.com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
12us t L,'�c.IN A-vt
Address: �bY Permit#:12�01%02%Zu
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): 9�5 6 l `b�iC < Company L l�i�,y n �r �%mac ��/� j
Technician Signature: Date s / / -7
Appliance Tested: f-16 41, �L t r ,4-eA-
Appliance Replaced: I `
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): t'
Date Tested:
Pass ✓ Fail
Natural Conditions: .
Spillage Duration gym' seconds): , Carbon Monoxide (parts per million):
Pass _Fail Date Tested:
(Failed test rewires 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