HomeMy WebLinkAbout1120 City Park Ave - Special Inspections/Combustion Safety - 12/29/2016From:
01/10/2017 16:22 #376 P.002
D
City of
/00"*F6rt Collins
�
Planning, Development & Transportation Services
Community Development a Neighborhood Services
281 Nonh College Avenue
P.O. Box 580
Fort Collins. CO 80522.0580
970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form
i Replacement of Natural Draft Appliances in Existing Houses
Address: I' ORO L�� �`{ �(� > I �s Permit Number: 151 JIlJ
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
A ,Version 5, February 2012.
Technician Name (print):
-1 Technician Signature: _
Appliance Tested: _1-1
Appliance Replaced: `�
4 Worst Case Conditio s:
Spillage Duration (in sec 'so 3
Pass Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
. Carbon Monoxide (parts per million):
Date Tested:
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:
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 1 have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature _
CST: replacement/natural-draft/4.25.12
Date