HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 10/04/2017Development
� R i s P6 BoxCollege Sao
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Fort Collins. co 80522
Ya 'i 97041a2748
970.224.6134 (fax)
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Combustion Safety Test Compliance Form
Replacement of Nataral Draft Appliances in leg Houses
Address: '! Permit # S 1-7.074q
Approved Agency:
I hereby attest that I have performed the fo
Fort Collins �g Combusdoa Safety Test m accordance with
Coma "Safety Test Guide Version 5, February 2012.
Technician,Tame-&-MA): !I✓1 Coro
Technician Signature: Date; IK y / 7
Appliance Tested:
Appliance Replaced: I
Worst Case Conditions: U
Spillage Duration (in seconds): �S�G Carbon Monoxide (ports million):
Pass Fail Date Tested: /v " 7`
Natural Conditions:
Spillage Duratio din seconds): _ Carbon Monoxide (parts per million): _
Pass Fail Date Tested:
(Filled test rephw taonw"ns fimW test prances =der Nab=[ Coafiem)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I eertify that I am the regal owner of the above listed property and hereby acknowledge that my appliance
has faihs3 a Combustion Safety Test under worst -case conditions. I acknowledge that I have received a
combustion appliance safety information sheet 11
Owner's Name (print)
Owner's Signature Date
CST• 42S.I2