HomeMy WebLinkAbout1208 Crestway Ct - Special Inspections/Combustion Safety - 01/04/2017From: 4Z
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City of
Fort Collins
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01/10/2017 16:07 0375 P.002
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North 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
Replacement of Natural Draft Appliances in Existing Houses J�
Address: ^ I Permit Number: I 0D I
Approved Agency: _7F
I hereby attest that 1 have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
V rsion 5, February 2012,
Technician Name (print): Ajj Company r
Technician Signature:
Appliance Tested:
Appliance Replace
Worst Case Conditions:
Spillage Duration (in seconds • 2 y
Pass Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
_ Date
Carbon Monoxide (parts per million): _4�
Date Tested:
Carbon Monoxide (pans per million):
Date Tested:
(Failed rest requires corrections until lest 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 1 have received a
combustion appliance safety information sheet. .
Owner's Name (print)
Owner's Signature _
CST: replacement/natural-draft/4.25.12
Date