HomeMy WebLinkAbout2720 Purple Mountain Ln - Special Inspections/Combustion Safety - 02/16/2017I
Community Development
Ci df 281 N. College Ave.
FVort Collins P.O Box580
Fort Collins, CO 80522
970.416.2740
9170,224.6134 (fax)
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing N
Address: 1?ao 72,rnlp IMoutIe, (C J Permit#: Z1604
Approved Agency: i
I hereby attest that I have performed the following Combustion Safety Test in' accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print): Toy. A.64,,, Company Fi4elrai
Technician Signature: Date !;?A / 11
Appliance Tested:
Appliance Replaced:
XC,+07'h0
Worst Case Conditions: f
Spillage Duration (in seconds): 10 Carbon Monoxide (parts per million): S
Pass IFail Date Tested:
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural
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 fated a Combustion Safety Test under worst -case conditions. I acknowledge that I have received a
m ustion appliance safety information sheet.
ptzSSc� ,
Owner's Name (print)nJ[1t9
Owner's Signature
CST: replacement/natural-draft/4.25.12