HomeMy WebLinkAbout3124 Conestoga Ct - Special Inspections/Combustion Safety - 04/17/2018Cites of
IFor. t. Coll.Ins
Planning, Developmtsnt.&Transportation Services
community Development 8 Neighborhood Services
•281 North College Avenue
P:O. BOX 580
Fort Coilins. CO 80522.0580
970.416.2740
070.224.8134-fex
fcgovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses .
31
Permit Number: gi
Address: g- 1 t l —
Approved Agency: , IF}Rl4 Pd-
TechnicianName(print): 41T'�1i5' ���" Company —
LLLL
Date
-Technician Signature:'
Appliance Tested: A-/-
Appliance Replaced: L !" ��' VIEW —
Worst Case. Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): ' �n
Pass _ . Fail _I Date Tested: <_—_ _J�
(Failed test requires owner's signature acknowledging results.) '
Natural. Conditions:
Spillage Duration (in seconds):
Carbon Monoxide (parts per million):
Pass Fail _ Date.Tested:
(Failed test requires- corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
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 receiveda. combustion appliance safety information sheet.
Owner's Name (print) .
owner's Signature -
Date