HomeMy WebLinkAbout2921 Timberwood Dr - Special Inspections/Combustion Safety - 09/22/2017Commmtlty Dwdopment
e 281 N. College Ave.
PO Box 580
Fort CoWns, CO 80522
471t.4982740
970.224.6134 (fax) _
' _ ' � �� Icgat,comtdsvelw�ment
Combustion Safety Test Compiianm Form
RegiseeatW of Natural draft Appliances is Existing Houses
Address: ZCi 21 ttita o�� ��� Permit #
Approved Agency;
I hereby attest that I have performed the following Combustion SaftY Fort Collins Combustion Test in accordance with
� Safet}''F�st Guide Version 5, February 2012.12.
TechmcianWame.(priut): Company � ( COS
Technician Signature: ��
Appliance Tested: �!) �� /1 G -I-.,- �._ i __ >a , .. � _
Appliance Replaced: I t " jt
WOW Case Conditions: QQ
Spillage Duration (in seconds): Esc c. Carlson Monoxide (parts million): /y
Pass Fail Date Tested -
Natural Conditions:
Spillage DwWarm seconds): 2jL4L_ Cron Monoxide (parts per million):
Pass Fail Date Tested.• Z
(Faded m w regwres correogm and, test posses utrderl0ratsrre! Cvnftotes)
Technician's recommendations to correct tested appliance failure:
Failed Wgrst Case Conditions:
I certify that I art the legal owner of the above listed property and hereby acknowWW that my appliance
has faM a Combustion Safety Test miter worsts conditions. I acknowledge that I have received a
combustion appliance safAy Information sheet.
Owner's Name (print)
Owner's Signature Date
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