HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 12/08/2016Planning, Devefopment & Transportation Services
Colons
..For, t
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
Address:PermitN.,er:,�j(i6-j_jL14-?
Approved Agency:
I h6reby 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
/7 Yftsion 5, February 2012.
Technician Name (print): Company V/#74r7Y7
Technician Signature: Date lZI-0-11ze
Appliance Tested: 1,//g iea /.424
Appliance Replaced:
Worst Case -Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): 16
Pass Fail
Natural Conditions:
Spillage Duration.4in seconds):
N_ Pass Fail
Date Tested:
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until testpayses 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-Mlacement/naftirakhN4.25.12
Date