HomeMy WebLinkAbout3474 Shallow Pond Dr - Special Inspections/Combustion Safety - 01/04/2017Cat r Of
Fbrt Colt -ins,
Planning, Development. & Transportation Services
Community Development & Neighborhood Bervlces
281 North College Avenue
P.O. tox 680
Fort Collins. Co 80622.0680
e7GAIS.2740
870.224.6134-fax
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Combustion Safety Text Compliance Form
Replacement of Natural Draft Appliances in Eslsting Houses
Permit Number:
Address:
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Approved regency: _
TechnicianNeme t)• J G any
Technician Sign at / — Date
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Appliance Tested: 5n ti c ��un (�� I�a�ef '� ear
Appliance ReTlT.ced: '
Worst Case. Conditions: , Z
Spillage Duration (in seconds): , 3 Carbon Monoxide(parts per million): '
Pass X Fail DAte Tested: 1-7
— - - -=(Palled "f¢st regrrirecos�s �1+ acicowledging results.) --
-
Natural: C®nditionse
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
.Pass Fail Date Tested:
(Felled test requires corrections until W pawa under Natural Condldons.)
Technician's recommendations to correct tested appliance failure:
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 Date