HomeMy WebLinkAbout3450 Lost Lake Pl - Special Inspections/Combustion Safety - 04/11/2017of
F6tyrt
Collins
O it t:,Y"
Community Development
281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
3,11
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address`Z-OrrG_+-Ke��) ��3 Permit #: /E% 7�IS41/
Approved Agency:
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): tS?�or 1l� Company
Technician Signature:
Appliance Tested: 16:1� k r
Appliance Replaced: bll*k_�
Worst Case Conditions:
Spillage Duration (in seconds):
Pass X' Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Date y—// —/�
Carbon Monoxide (parts per million):
Date Tested: I — // —/ _�7
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
A)o
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. 1 acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST: replacemendnatural-draft/4.25.12
Date