HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 07/08/2016�i Community Development
Fort Collins ty of 281 N. College Ave.
PO Box 58080
n Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
\ /cgov com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: %(� 1��1G'►"7"1' — _ p? Permit
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion SLety Test Guide Version 5, February 2012.
Technician Name (print): t'Gpl ` Company (�j l(��n✓(/� if �0���°�'
Technician Signature: Date II
Appliance Tested: Lf& UY\ ^ hkti7
Appliance Replaced: It n
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts er million):
Pass Fail Date Tested: -7
Natural Conditions: -
Spillage Duration (iti seconds): Carbon Monoxide ()arts per million):
Pass _Y,' Fail Date Tested: %0 t o
(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: replacement/natural-draft/4.25.12
Date