HomeMy WebLinkAbout648 STOVER ST - SPECIAL INSPECTIONS - 1/16/2013Community Development
F6rt C1ty ok 181 N. College Ave.
Cofts PO Box 580
Fort Collins, CO 80522
970A16.2740
970.224.6134 (fax)
kgov-com/development
Combusiflon Safety Test CoxnpHance Form
Roplacement of Natural Draft Appliances in Existing Houses
Address: _ 6 �1$ _ .5JTO&-, �e SY Permit #:
Approved Agency.
I hereby attest that I have peri'omed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print): rQ _�a u,ou Company ;Pe/-Z21/1il a �r.cst f
Teelmician Si_bop-Hr.,:: _ Date
Appliance T ested: __ _
Appliance kepi&c6d:
Worst Case Conditions:
Spillage Dumtion (in seconds): / � Carbon Monoxide (parts per million): �b --
Pass Fail _ Date Tested: > /6 l 3
Natural Cowdil`,�,tase
Spillage Duration (in seconds): 1. r� Carbon Monoxide (parts per trillion): %6
Fail Date Tested:
(1%W tesi requires corrections until testpasses underNataral Conditions)
Technician's recommendations to correct tested appliance failure
Failed Woysi C:Ise Coudiitions:
I certify that I atr.• tit!: legal o(xmer of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Saf-oty Test under worst case conditions. I acknowledge that I have received a
combustion appliance safety Wbrmation sheet.
Owner's Name (print)
Owner's Signature
CS1':replacerr-s:t.'ua�u
Date
l 'd SttiL'ON M[-:l EIR •Ll'uPr