HomeMy WebLinkAbout431 DERRY DR - SPECIAL INSPECTIONS - 1/22/2013tZ
(Ing, Development & Transportation Services
Clg Community Development & Neighborhood Services
tJ' 281 North College Avenue
F6r` Collins P.O. Box580
Fart Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
icgovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 1—; �j jy '�� Permit Number:
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012.
Technician Name
Technician
Appliance Tested:
Appliance Replaced:
RAJ i�-I�J
Date
Worst Case Conditions:
Spillage Duration (in seconds): 2DO Carbon Monoxide (parts per million): 14
Pass Fail Date Tested: j 2Z V3
Natural Conditions:
Spillage Duration (in seconds): 1 for 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:
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