HomeMy WebLinkAbout3036 Dunbar Ave - Special Inspections/Combustion Safety - 02/15/2017From:
02/16/2017 10:36 #389 P.002/002
Flirt Collins
Planning, Development & Transportation Services
Community Development t: Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.01�
970AI6.2740
970.224.6134-fax
rcgov.Com
Combustion Safety Test Compliance Form 111\t}
Replace ent of Natural Draft Appliances in Existing Houses 4
Address: JC&I - Permit Number: 1 CQ 0 J�
Approved Agency:
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
Vers' n 5, February 2012.
Technician Name (print): Gf I/m Company (,(9 J / ►'r°
Technician Signature: Date 2�-
Appliance Tested: (,06i,,r- In G
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass . Fail _ Date Tested:
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test posses under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I certify that I ant the legal owner of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst -case conditions. 1 acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature Date
CST: replacement/natural-draft/4.25.12