HomeMy WebLinkAbout2715 Saddle Creek Dr - Special Inspections/Combustion Safety - 04/13/2018City ®f
Fort Collins
Community Development
281 N. College Ave.
PO Box 580
Fort Collins, CO80522
970.416.2740
970.224.6134 (fax)
kgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existi I g Houses
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Address: o< i� S C+ �b r— Permit #: 2 / W� (� �f7
Approved Agency:
I hereby attest that I have performed the following Combustion Safety lest in accordance with
Fort Collins Combustion Safety Test Guide Version 5; February 2012.
Technician Name (print):
Technician Signature:
Company 64 PS 2�Lj, C—
Date 1/—/3—f9
Appliance Tested: hli�f
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seco ds): Li q Carbon Monoxide (parts per million):'
Pass T Fail Date Tested: —49
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
U6 Ile J e, e-Cj;
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. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST:replacement/natural-draft/4.25.12
Date