HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 08/09/2016p�
Community Development
City of 281 N. College Ave.
Fort Collins PO Box 580
�` Fort Collins, CO 80522
970.416.2740
970.224.6134 (tax)
�\ (cgov,com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: % A4ue'a*)S -r�21�
. v1 Permit#:� }�(005C cl
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): Ars5 Vg l�(to�,RC Company FlIm'. 15ev,'C;z CA.u9u� y
Technician Signature: Date
Appliance Tested: fl=,+C L Uo
Appliance Replaced: 9,20 C,4-r-x Ko
Worst Case Conditions:
Spillage Duration (in seconds):_ Carbon Monoxide (p rts pet million):
Pass —Z Fail Date Tested: /
Natural Conditions:
Spillage Duration din seconds): �_ Carbon Monoxide (parts er million):
Pass ✓ Fail Date Tested: -7
(Failed test requires corrections until test passes under Natural Conditions)
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 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:replacementhiatural-draft/4.25.12
Date