HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 08/01/2016q Community Development
281 N. College Ave.
F6 VOl l' n s PO Box 580
:,-»M ` Fort Collins, CO 80522
970.416.2740
970,224.6134 (fax)
f
fcgov.com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 6� ��v/ t �Q�o�(r�`� Permit
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.
Teclmician,Name (print): I Company `t.1
Technician Signature: Date
Appliance Tested: t� az
Appliance Replaced: I' It It
v ft 14 ' I
Worst Case Conditions: '7
Spillage Duration (in seconds): Carbon Monoxide (parts p r million): /
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (ui seconds): _ Carbon Monoxide (part per million):
Pass � Fail Date Tested: 40 i
(Failed test requires corrections until test pusses 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/natura l-draft/4.25.12
Date