HomeMy WebLinkAbout709 Keenesburg Ct - Special Inspections/Combustion Safety - 01/16/2017Planning, Development & Transportation Services
Clty. of �� Community Development & Neighborhood Services
281 North College Avenue
• . P.O. Box 580
Fort.Collins..)z Fort Collins, CO80522.0580
�... 970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: -6/it4t1ry C+ Permit Number:-6�Z
Approved Ag4ncy
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
Version 5, February 2012
Technician Name (print): u_T'm Company ?0J bCy f eP1 AC4 Ab3
Technician Signature: Date 111017
Appliance Tested: a inra� 1 U A
Appliance Replaced:
Worst Case Conditions: Spillage Duration (in seconds): 16 Carbon Monoxide (parts per million):
Pas Fail Date Tested:
Natural Conditions: Ir�
Spillage Duration (i econds): � Carbon Monoxide (parts per million):
Pass Fail Date Tested: 1//6/1-f
(Failed test requires corrections until testpasses 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: rep lacement/natural-draft/4.25. 12
Date